Form 700 Participant Application for Pension Benefits

Participant Application
for Pension Benefits

PBGC Form 700

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

For assistance, call 1-800-400-7242

Plan Name:
Plan Number:
Date Printed:
Date of Plan Termination:

Participant Name:

INSTRUCTIONS: Please complete this form to apply for your pension benefits. For those items marked “Proof
Required”, enclose a copy of the appropriate document if you have not already sent it to us. Acceptable
documents for proof of age include your birth or baptism certificate, or U.S. passport; for marriage, a marriage
certificate. Please make sure that proof documents are legible before sending to PBGC. If you have questions
about other acceptable documents, call our Customer Contact Center at 1-800-400-7242. Print clearly with blue
or black ink.

1. General information about you
Last Name

First Name

Middle Name

Other last name(s) used

Social Security Number

Date of Birth (Copy of Proof Required)

-

-

/

Gender

/

Mailing Address

Apartment / Route Number

City

State

Country

Email

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

Extension

)

MALE

x

(

)

/

Please enter your actual retirement date (ARD) using the date from the
Optional Benefit Form that provides the amounts of your benefit options.

Month

Year

This is the first date as of which you will receive benefits, your first payment date
may be later. .
Will you be employed on the date above?
Employer Name:

Yes



No



State

City

If you are employed by the company that sponsored your pension plan on your actual retirement date, contact PBGC to
confirm your eligibility before submitting this application. If you return to work for the company that sponsored your
pension plan, notify PBGC immediately.

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CONTINUE ON BACK

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Participant Application for Pension Benefits
Plan Number:

Form 700, page 2 of 6

Participant Name:

2a. Marital status - Please complete both 2a. and 2b.
Are you currently married?

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Last Name(s) Used

Spouse’s Social Security Number

-

Spouse’s Date of Birth

Date of Marriage

(PROOF REQUIRED)

(PROOF REQUIRED)

-

/

/

/

Yes



No



/

2b. Court order related to the participant’s benefit
Is there a court order (for example - domestic relations order, divorce decree, child
support order, etc.) that requires some or all of your benefit be paid to a spouse, former
spouse, child, or other dependent?

Yes



No



_________________________________________________________________________________
3. Election of Benefit Form – Before you choose an option below, please read the examples in Your Benefit,
Your Choice (attached to this application). Refer to the calculations included in your package that show
the amount of your benefit under the Plan’s Automatic Forms (options A and B) and the amount under
PBGC’s Optional Benefit forms (options C through J) with your spouse or other beneficiary requested.
NOTE: You cannot change your benefit election (marked below) after PBGC makes the first payment to you.

My Choice

Beneficiary

MARK ONLY ONE

MARK ONLY ONE

A. Plan’s Automatic Form for an Unmarried
Participant

Benefit Form



Not Applicable

B. Plan’s Automatic Form for a Married Participant



Spouse only

C. Straight Life Annuity



Not Applicable

D. Joint-and-50% Survivor Annuity



 Spouse

or

 Other Beneficiary

E. Joint-and-75% Survivor Annuity



 Spouse

or

 Other Beneficiary

F. Joint-and-100% Survivor Annuity



 Spouse

or

 Other Beneficiary

G. Joint-and-50% Survivor “Pop-up” Annuity



 Spouse

or

 Other Beneficiary

H. 5-year Certain-and-Continuous Annuity



 Spouse

or

 Other Beneficiary



 Spouse

or

 Other Beneficiary



 Spouse

or

 Other Beneficiary

Certain payment period starts on ARD in Section 1.

I. 10-year Certain-and-Continuous Annuity
Certain payment period starts on ARD in Section 1.

J. 15-year Certain-and-Continuous Annuity
Certain payment period starts on ARD in Section 1.

•

•

If you are married and do not choose Benefit Form “B”, your spouse must complete Section 4 on page 3.
If you chose “Other Beneficiary” in options D through J above, you must complete Section 5 on page 4.
CONTINUE

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Participant Application for Pension Benefits
Plan Number:

Form 700, page 3 of 6

Participant Name:

4. Spousal consent to elected form of benefit and beneficiary.
If you are married, and chose Benefit Form B (page 2), leave this section blank.
If you are married and did not choose Benefit Form B (page 2), your spouse must consent to your choice by
signing below. Your spouse’s consent must be signed in the presence of or acknowledged by a notary public.
If your spouse does not consent, PBGC will not begin to pay your benefit.
By signing below, I consent to my spouse’s election of the benefit form checked in section 3 and the
beneficiary designated in section 5. My consent is voluntary. I have read and I understand the information
provided with this application. In particular, I understand all of the following:
•

I have a right not to consent to my spouse’s election.

•

If I do not consent, my spouse’s benefit will be paid in the plan’s automatic form for married
participants. Under that automatic form, if my spouse dies before me, I would receive a benefit equal
to at least 50% of my spouse’s benefit for the rest of my life.

•

If I do consent to my spouse’s election, survivor benefits, if any, will be paid according to the benefit
form and beneficiary designation elected by my spouse. As a result, if my spouse dies before me, I
may not be entitled to any survivor benefits.

•

If my spouse elects a certain and continuous annuity (choice H, I, or J in section 3), and if I consent to
this election, my spouse can make future changes to the beneficiary without my consent.

•

If I do consent to my spouse’s election, I cannot revoke my consent after PBGC makes the first
payment to my spouse.

SPOUSE’S SIGNATURE (MUST BE NOTARIZED)

DATE

To be completed by Notary Public:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
DATE MY COMMISSION EXPIRES

NOTARY PUBLIC NAME

CITY / COUNTY

STATE

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Participant Application for Pension Benefits
Plan Number:

Form 700, page 4 of 6

Participant Name:

5. Designation of “Other Beneficiary” for Continuing Payments. Complete this section if you elected any benefit
form from D through J in Section 3 and checked “Other Beneficiary”. If you elected a joint-and-survivor annuity, your
beneficiary designation is final and cannot be changed after PBGC makes your first payment. If you elected a certain-andcontinuous annuity, you may change your beneficiary at any time.
Note: The beneficiary will receive benefits that continue after your death, and will also receive any additional
money owed to you at your death.
Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth (PROOF REQUIRED FOR

-

Gender

JOINT AND SURVIVOR BENEFITS ONLY)

-

/

/

Mailing Address

Apartment / Route Number

City

State

Country

Email (optional)

Daytime Phone

(

EXTENSION

)

-

x

MALE



FEMALE



Zip Code

Evening Phone

(

)

-

Relationship to you, if any (for example - granddaughter, friend)

6. Designation of Beneficiary for Payments Owed at Death. PBGC may owe you monies that are not continuing
payments at the time of your death. The person(s) or entity(ies) you designate in this section will receive the money if the
person you named for continuing payments dies before you or if you chose Option A or C in section 3. If you do not make
a designation, PBGC will pay the money in this order: your spouse, your children, your parents, your estate or your next of
kin.
Beneficiary(ies)*

Social Security Number**

Date of Birth**

Relationship*

Percentage***

Name ____________________________________
Address ___________________________________
__________________________________________
Daytime Tel. No:___________________________

Name ____________________________________
Address ___________________________________
__________________________________________
Daytime Tel. No:___________________________

*To name more beneficiaries, please list them with requested contact info, DOB and SSN on an attached sheet with your signature.
**Complete if person.
*** Percentage(s) does not have to be provided.
The amount owed will be distributed equally among beneficiaries unless percentages are provided for each beneficiary and they total 100%.
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.

CONTINUE

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Form 700, page 5 of 6

Participant Application for Pension Benefits
Plan Number:

Participant Name:

7. Method of receiving benefit payments. PBGC pays benefits through safe, secure and convenient electronic funds
transfer. You will get your payment on time even if you are out-of-town or unable to get to the bank.
If you have a bank account, you can ask us to deposit your benefit payments to your account through Electronic Direct
Deposit (EDD).
If you do not have a bank account, you can open a low-cost Electronic Transfer Account (ETA) at a financial institution that
offers such accounts. For more information about opening an ETA, call 1-888-382-3311 (toll-free) or visit the ETA website
at www.eta-find.gov.
Note: PBGC does not transfer funds to financial institutions outside the United States and its territories. If you live outside
the United States or its territories and do not have a U.S bank account, PBGC will send your payment to your mailing
address.

How would you like to receive your payments?

MARK ONLY
ONE



A. By EDD or ETA to the account identified below, which must have my name on it.
B. By mail to my home address, which is printed in section 1 of this form. You may choose this
option if EDD or ETA would be difficult or a burden because:
•
•
•



You do not have a bank account.
You reside in a remote location that does not have the infrastructure to support EDD or ETA.
It is too expensive for you to maintain a bank account.

Financial institution information – Please provide the information below for PBGC to send your payment directly
to a financial institution. The information is available from your financial institution or can be found on your checks and
account statements. The sample check below shows the location of your nine-digit routing number and your account
number. If you are unsure of the routing number or your account number, contact your financial institution. You
can cancel or change this arrangement by calling PBGC at 1-800-400-7242. The financial institution can cancel it by
sending you a written notice.

All fields required
Name(s) on the Account (Your name must be on the account)
Routing Number

Account Number – Numbers only

Account Type
Checking
Savings



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Participant Application for Pension Benefits
Plan Number:

Form 700, page 6 of 6

Participant Name:

8. Federal Tax Election – Complete this section by selecting only one option – A or B or C. If you live outside
the United States, you cannot select Option A. For additional guidance regarding these options and federal tax
withholding, please read page 4 of the enclosure: Your Benefit, Your Choice. Benefit Options from PBGC. In
general, tax laws require PBGC to withhold federal income tax from your pension payments unless you
specifically elect not to have taxes withheld. If you do not choose an option, if you choose multiple options
or if the option you select is incomplete, we will withhold federal income taxes as if you were a married
individual with three allowances. This means that for the year 20210 we will withhold taxes only if your
monthly PBGC benefit is $2,10095.00 or more.



A. I elect not to have federal income tax withheld. (Available to U.S. residents only.)

OR


B. I elect to have federal income tax withheld based on IRS instructions.
Marital Status (REQUIRED)

Single 

Married 

Number of withholding allowances (REQUIRED)

.00

Additional monthly amount to be withheld (optional): $

OR


C. I elect to have the following amount withheld for federal income tax.

.00

The dollar amount or percentage to be withheld monthly is: $

OR _____%

9. Signature – Sign and date this application. Knowingly and willfully making false, fictitious or fraudulent statements to the
Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, United States Code.
I declare under penalty of perjury that all of the information I have provided on this form is true and correct.

PARTICIPANT’S SIGNATURE

DATE

Please complete the checklist below to ensure that your application form has all the required signatures and proof
documents before you submit it. A MISSING SIGNATURE OR PROOF DOCUMENT COULD DELAY YOUR FIRST
PAYMENT.
1. Did you sign and date the application above?
2. Did you enclose a copy of your proof of age document? Your driver’s license is not a proof
document.
3. If you are married, did you enclose a copy of your marriage certificate?
4. If you are married, did you enclose a copy of your spouse’s proof of age?
5. If you are married and elected a benefit form other than option B on page 2, did your spouse sign
Section 4 on page 3 and was the signature notarized?
6. Did you elect only one option regarding federal tax withholding and is the election complete?

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