Form 720MP Application for Lump-Sum Payment - Missing Participant

	Application for Lump-Sum Payment		PBGC Form 720MP 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: 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.

1. General information about you

Last Name

First Name

Middle Name

Other Name(s) Used

Social Security Number

Date of Birth (Copy of Proof Required)

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Province

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

If you are the participant and worked after the date the plan terminated, what year did you stop working for the employer who sponsored your pension plan?

Year

CONTINUE

Application for Lump-Sum Payment Form 720MP, page 2 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2. Payment Election – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC pay the lump sum 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. 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 the entire payment, plus interest, directly to me. I understand that PBGC will withhold 20% of the taxable amount of my 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.

If you elected option A or C, complete Section D on page 3.

CONTINUE

Application for Lump-Sum Payment Form 720MP, page 3 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name : FX.PrismCust.FullName.XF

Payment Election (Continued)

D. Rollover Information

Name of IRA or Plan:

Type of IRA or Plan: Traditional IRA    Roth IRA Qualified retirement plan

Account Number

Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address

City

State

Zip Code

-

3. Signature – Sign and date this application in the presence of 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 witnessing your signature above:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
Date My Commission Expires		Notary Public Name
City / County		State