Form 703RBB-MP Application for Elective Lump-Sum Payment, post RBD

Application for Elective Lump-Sum Payment, post RBD

PBGC Form 703RBD-MP

For Assistance Call 1-800-400-7242

Pension Benefit Guaranty Corporation
Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750
Participant Name:
Plan Name:
Plan Number:
Date Printed:
Date of Plan Termination:

INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a copy of
your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s spouse, enclose a copy of your
marriage certificate if you have not already sent it to us. Please make sure that proof documents are legible before
sending to PBGC. If you have questions about other documents we accept as proof, call our Customer Contact
Center at 1-800-400-7242. Print clearly with blue or black ink.

Section 1: General Information About You
Last Name

First Name

Middle Name

Other Last Name(s) used

Social Security Number

Date of Birth MM/DD/YYYY
PROOF REQUIRED

1

2

3

-

5

5

-

6

7

8

9

M M

/

D

D

/

Y

Mailing Address

Apartment / Route Number

City

State

Country

Province

Primary Phone

Phone Type

(

5

5

5

)

3

4

5

-

6

7

8

9

Secondary Phone
(

5

5

5

)

Y

Gender
Y

Y

 MALE
 FEMALE

Zip Code

 Home
 Mobile
Phone Type

3

4

5

-

6

7

8

9

 Home
 Mobile

Approved OMB 1212-0055
Expires _________

Application for Elective Lump-Sum Payment, post RBD

PBGC Form 703RBD-MP

Plan Number:
Participant Name:

Page 2 of 5

Section 2a: Marital Status - Please complete both 2a. and 2b.
Are you currently married?

Yes

No

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Last Name(s) Used

Spouse Social Security Number
-

-

Date of Marriage
MM/DD/YYYY
PROOF REQUIRED

Spouse Date of Birth

MM/DD/YYYY

/

/

/

/

Section 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

Section 3: Lump-sum payment election
If you are the participant, you and your spouse have to make an important decision about how your benefit is paid.
Important Information about Your Benefit Choices
You need to decide whether you want to receive your benefit as a single lump-sum payment now or as a monthly annuity
benefit . If you are currently married and want a lump-sum payment, your spouse’s consent is needed for PBGC to comply with
your election.
If you complete this application and your spouse consents on the next page to your election, PBGC will pay your entire benefit to
you in a lump-sum. No annuity benefits will be payable to you or your spouse. If you would prefer to receive your benefit in a
monthly annuity form, call PBGC and do not submit this application.
Annuity Benefit Form
At the time that you are eligible to retire, PBGC will pay your benefit as an annuity, generally monthly, for your life. The form of
your annuity benefit will depend on your marital status at retirement. If you are married, you will receive a joint-and-survivor
benefit unless your spouse consents to your waiver of this form of benefit in writing. The joint-and-survivor form provides a
benefit for your life and, if you die before your spouse, at least 50% of your benefit amount will be paid to your spouse for the rest
of your spouse’s life. To help pay for your spouse's benefits, your payment will most likely be reduced. If your spouse consents
to your waiver of the joint-and-survivor benefit, or if you are not married, you may select from a number of PBGC optional benefit
forms.

Approved OMB 1212-0055
Expires _________

Application for Elective Lump-Sum Payment, post RBD

PBGC Form 703RBD-MP

Plan Number:
Participant Name:

Page 3 of 5

Lump-Sum Payment
You will receive a single payment now of your entire benefit. No annuity benefits will be payable to you or your spouse.
An example of your choices:
Lump-sum payment: Sam elects a lump-sum payment and Carol consents to it (Carol signs in front of a notary public), and Sam
receives $7,000 in the form of a single lump-sum benefit, with interest. No future payments will be payable to Sam or Carol.
Joint-and-50% survivor annuity: Sam (age 74) and Carol (age 69) are married when Sam retires. Sam receives a payment of $260 for
the rest of his life. After Sam dies, Carol receives $130 a month for the rest of her life. If Carol dies first, Sam will continue to receive
$260 a month for the rest of his life.
Other annuity choices: If Sam waives a joint-and-survivor annuity when he retires, and Carol consents to his waiver, other annuity
benefit forms are available. To learn more about your specific annuity benefit choices, call PBGC at 1-800-400-7242.

Section 4: Spousal consent for a participant to receive an elective lump-sum benefit.
If you are married and want to receive your benefit in a lump sum or single payment, your spouse must complete this
section.
Your spouse’s consent must be signed in the presence of or acknowledged by a notary public.
By signing below, I consent to my spouse's election to receive his/her benefit in a lump-sum or single payment. 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 of a lump-sum payment.

•

If I do not consent, my spouse’s benefit may only be paid in the automatic form for married participants. Under that
automatic form, if my spouse dies before me, I will 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 of a lump-sum payment, I cannot revoke my consent after PBGC makes the
payment to my spouse.

SPOUSE’S SIGNATURE (MUST BE NOTARIZED)

DATE

Must be signed by a Notary Public

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

Approved OMB 1212-0055
Expires _________

Application for Elective Lump-Sum Payment, post RBD

PBGC Form 703RBD-MP

Plan Number:
Participant Name:

Page 4 of 5

Section 5: 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 payment to your account through Electronic Direct Deposit
(EDD).
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 payment?
My Choice
MARK ONLY ONE
By EDD to the account identified below, which must be titled in my name although it is fine for
there to be joint or other co-owners on the account.
B. By mail to my home address, which is printed in Section 1 of this form.

Financial Institution Information
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.

Or Attach a VOIDED check to this application.

Do not complete below if VOIDED check is attached to this application.
Name(s) on the Account
(Your name must be on the account):
Routing Number:

Account Number – Numbers only:

Account Type
Checking

Savings





Approved OMB 1212-0055
Expires _________

Application for Elective Lump-Sum Payment, post RBD

PBGC Form 703RBD-MP

Plan Number:
Participant Name:

Page 5 of 5

Federal income tax withholding election – Check A, or B or C below (check only one). If you do not choose an option or check
more than one option, PBGC will automatically withhold 10% of the payment for federal income tax. If you do not have tax
withheld or you do not have enough tax withheld, you may be responsible for any tax liability, interest, and penalties, and may
have to make estimated tax payments to the IRS. You may want to consult with the IRS or a tax specialist before you make your
withholding election.
A. Do not withhold federal income tax from this payment.
B. Withhold $_______.00 from the payment for federal income tax.

C. Withhold 10% (or other ____ %) from the payment for federal Income tax.

Section 6: Signature
Sign and date this application in the presence of or acknowledged by a Notary Public. 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.

SIGNATURE

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

Approved OMB 1212-0055
Expires _________