Form 713 Form 713 Election to Withdraw Employee Contributions

	Election to Withdraw Employee Contributions		PBGC Form 713 Approved OMB 1212-0055 Expires
Pension Benefit Guaranty Corporation. P.O. Box 151750, Alexandria, Virginia 22315-1750		For assistance, call 1-800-400-7242

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF
	Date Printed: 01/30/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Complete this form to elect whether to withdraw contributions made to the above pension plan in a single sum. Please read the cover letter and this form carefully before you make an election. If you have questions, call our Customer Contact Center at 1-800-400-7242. Please print clearly with blue or black ink.

1. General information about you

_{Last Name}

_{First Name}

_{Middle Name}

_{Social Security Number}

_-

_-

_{Mailing Address}

_{Apartment / Route Number}

_City

_State

_{Zip Code}

_Country

_Email

_{Daytime Phone}

_Extension

_{Evening Phone}

₍

₎

_-

_x

₍

₎

_-

_{Mark One}

_{Your relationship to the person who participated in the plan:}

_

_{Self – The benefits are from my pension plan. I am: Married  Not Married }

My date of birth:

/

/

_{The year I last worked for the Company that sponsored this pension plan was: ________}

_

_{Spouse - The benefits are from the pension plan of the participant who is deceased.}

_{Participant’s name:}

_{Participant’s Social Security Number}

_{Participant’s Date of Birth}

_{Participant’s Date of Death}

_-

_-

_/

_/

_/

_/

_

_{Alternate payee - I have a court order that establishes my right to receive some or all of a participant’s benefits from a pension plan.}

_{Participant’s name:}

_{Date of Order:}

_/

_/

^CONTINUE

Election to Withdraw Employee Contributions Form 713, page 2 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF

2. Election – Choose A or B. You may withdraw the contributions anytime before you retire or when you apply to start your pension benefits. Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments before you make an election and be sure you understand the implications of withdrawing the contributions.

Option A – You can only elect this option if you are applying for pension benefits at this time.

Option B –You can elect this option to 1) withdraw your contributions before you retire or 2) withdraw your contributions when you are applying for pension benefits.

1. _{Election Not To Withdraw Employee Contributions}

_{If you are applying for pension benefits and do not want to withdraw your contributions in a single sum, check the box below and sign and date this page.}

Election Not to Withdraw Employee Contributions

I am applying for pension benefits. I elect not to withdraw the employee contributions in a single sum and to receive my pension which includes the amount derived from the employee contributions.

I understand that I cannot change this election after the 90-day period ends, or if earlier, the date that my pension benefit payments begin.

Signature – Sign and date this form. 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

_{If you completed this section, return only pages 1 and 2 to PBGC}

^CONTINUE

_{Election to Withdraw Employee Contributions Form 713, page 3 of 5}

Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF

_{B. Election to Withdraw Employee Contributions}

If you want to withdraw the contributions (plus interest) in a single sum, check the box below and complete the remainder of this form. If you are the participant and you are married, your spouse must complete section 3.

Election to Withdraw Employee Contributions

I elect to withdraw the contributions, plus interest, in a single sum. I understand that withdrawing the contributions now will result in a smaller pension payment.

I understand that I cannot change this election after PBGC pays the contributions (plus interest) to me.

If you are married, go to Section 3; otherwise go to Section 4.

3. Spouse’s consent for withdrawal of employee contributions – If you are the participant and you are married, your spouse must complete this section and sign and date it in the presence of a Notary Public witnessing his/her signature.

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Name(s) Used

Spouse’s Social Security Number

Date of Marriage

-

-

/

/

By signing below, I consent to my spouse’s election to withdraw his or her pension contributions, plus interest, in a single sum. I have a right not to consent to my spouse’s election. I understand that as a result of agreeing to the withdrawal of my spouse’s contributions in a single sum that any spousal benefit that I may receive will be reduced. My consent is voluntary and I also understand I cannot revoke my consent after PBGC pays the contributions, plus interest, to my spouse.

signature of spouse							date
To be completed by Notary Public witnessing your signature above:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
Date My Commission Expires					Notary Public Name
City / County					State
		CONTINUE						
Election to Withdraw Employee Contributions Form 713, page 4 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF		Participant Name: FX.PrismCust.FullName.XF

4. Payment Election– Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments and be sure you understand the tax implications of electing to have PBGC pay the contributions directly to you or to an individual retirement arrangement (IRA) or a qualified retirement plan.

Please elect only one option - A or B or C or D. If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.

A. Roll over my payment to an IRA or a plan – Send my entire payment, plus interest, directly to an IRA or a qualified retirement plan. I understand that PBGC will not withhold taxes from my payment.



B. Pay me directly – Send my entire payment, plus interest, directly to me. I understand that PBGC will withhold 20% of the taxable amount of this payment for federal income tax.

 

C. Split my payment - Send some of the money, plus interest, directly to me, and send some directly to an IRA or a qualified retirement plan, as follows:				
	1. Send this much directly to me:	$							.
	I understand that PBGC will withhold 20% of the taxable amount for federal income tax.
	2. Send this much to an IRA or a qualified retirement plan.	$							.
	I understand that PBGC will not withhold taxes from this part of my payment. Note: the amount must be at least $500.
	.

D. Split my payment between Taxable and Non-taxable amounts. Send the non-taxable amount directly to me AND the taxable amount to an IRA or a qualified retirement plan. I understand that PBGC will not withhold federal income tax from either payment.



If you elected option A or C or D, complete Section E on page 5.

		CONTINUE		
Election to Withdraw Employee Contributions Form 713, page 5 of 5
	Plan Number: FX.PrismCase.CaseIdNmbr.XF		Participant Name :FX.PrismCust.FullName.XF

Payment Election (continued)

E. Rollover Information

Name of IRA or Plan:

Type of IRA or Plan (check one): Traditional IRA Roth IRA Qualified Retirement Plan

Account Number

Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address

City

State

Zip Code

-

6. Signature – Sign and date this form. 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