Form 718 Installment Payment Agreement

	Installment Payment Agreement		PBGC Form 718

	Plan Name: FX.PrismCase.CaseTitle.XF
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF
	Date Printed: 01/15/2021
	Date of Plan Termination: FX.PrismCase.DOPT.XF

1. General information about you (Print clearly with blue or black ink)

Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth

Gender

male



-

-

/

/

female



Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Email

Daytime Phone

Extension

Evening Phone

(

)

-

x

(

)

-

INSTRUCTIONS: If you want to pay your debt in installments, please read and sign the agreement on the next page and send it to:

FOD/Collections and Compliance Division

Pension Benefit Guaranty Corporation

1200 K Street, NW, Suite 650

Washington, DC 20005-4026

The agreement may not be altered in any manner. After you sign and return the agreement, PBGC will sign and return a copy of this agreement to you, with instructions concerning your monthly payments. Monthly payments will be due by the last day of the month, beginning the month following the date PBGC executes the agreement.

CONTINUE ON BACK

Approved OMB 1212-0055

Expires xx/xx/xx

Installment Payment Agreement			Form 718, page 2 of 2
	Plan Number: FX.PrismCase.CaseIdNmbr.XF	Participant Name: FX.PrismCust.FullName.XF

2. Installment Payment Agreement

I acknowledge that I owe the Pension Benefit Guaranty Corporation (PBGC) a debt for monies that I received, but was not entitled to receive. The amount of this debt is entered below. In exchange for PBGC’s agreement to not demand payment at once of the entire amount of this debt or to take legal or other collection actions, I agree to make monthly payments in the amount indicated below until my debt is fully paid.

I understand that simple interest will accrue on the total remaining unpaid balance at the same rate as the U.S Treasury Department’s Current Value of Funds Rate. The U.S. Treasury Department calculates the rate annually and for _____ the rate is ___%. This rate will apply for the life of this agreement unless a default (as defined below) occurs. My payments will first be applied to outstanding interest, then to reduce the principal amount of the debt.

In the event of default in the payment of any of the installments, PBGC may, without notice or demand, declare the total debt (principal and interest) then unpaid immediately due and payable. For purposes of this agreement, PBGC defines “default” as an installment payment that is at least 90 days late. In addition, upon default of the debt, PBGC may charge a penalty of up to 6% annually on the outstanding debt. In the event of a default, PBGC may take one or more of the following actions: forward the debt to the U.S. Treasury Department for debt collection action, including tax refund offset, Social Security benefit offset, and/or wage garnishment; refer the debt to a collection agency; report the debt to a credit bureau; and/or, initiate litigation. If the debt is referred to the U.S. Treasury Department for debt collection action, PBGC will assess administrative costs incurred to collect the debt, in addition to collection fees the U.S. Treasury Department will charge.

After this installment agreement is signed by both parties, I may submit a request to modify or terminate the installment agreement. While PBGC considers my request to modify or terminate the installment agreement, I understand that I must comply with the existing agreement.

Total debt:	$____________
Monthly payment:	$____________ for ______ months
Final payment:	$____________ for one (1) month
PBGC Tracking number:	_________________

By signing this form, I agree to the terms set forth in this agreement.

___________________________________________	___________________
Signature	Date

Terms accepted by PBGC:

___________________________________________	___________________
Signature of FOD Collections Official	Date

____________________________________________

Printed Name of FOD Collections Official