Form 721 Application for Payment Eligible for Rollover – Non-Spou

	Application for Payment Eligible for Rollover – Non-Spouse Beneficiary		PBGC Form 721 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 if you are the beneficiary of a participant who has died and you are not the spouse. Please enclose a legible copy of the death certificate unless you have already sent a copy to PBGC. Please print clearly with blue or black ink.

1. Information about you

Last Name

First Name

Middle Name

Your Relationship to Deceased Payee

Social Security Number

Date of Birth

-

-

/

/

Mailing Address

Apartment / Route Number

City

State

Zip Code

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

CONTINUE

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Application for Payment Eligible for Rollover – Non-Spouse Beneficiary Form 721, page 2 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2. Payment Option – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC send your lump-sum payment directly to you or to an inherited individual retirement account (IRA).

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. Rollover my payment into an Inherited IRA – Send my entire payment, plus interest, directly to the inherited (IRA) I designate. I understand that PBGC will not withhold federal income tax from the payment.

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B. Pay me directly - Send the entire payment, plus interest, directly to me. I understand that I cannot rollover this amount later to an inherited IRA, and that PBGC will withhold 20% of the taxable amount of this payment for federal income tax.

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C. Split my payment - Send some of the money directly to me, and send some directly to an IRA as follows:			
	1. Send this much directly to me:	$						.
	I understand that I cannot rollover this amount later to an inherited IRA and that PBGC will withhold 20% of the taxable amount of this payment for federal income tax.
	2. Send this much to an inherited IRA.	$						.
	I understand that PBGC will not withhold taxes from this part of my payment to the IRA I designate. Note: the amount must be at least $500.00.		no less than $500

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

	CONTINUE

Application for Payment Eligible for Rollover – Non-Spouse Beneficiary Form 721, page 3 of 3
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

3. Information About Your Inherited Individual Retirement Account

Name of Receiving Account (example – Tom Smith as beneficiary of John Smith)

Account Number

Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address

City

State

Zip Code

-

4. 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.
SIGNATURE		DATE

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