Form 721T Tax Election for Payment Not Eligible for Rollover

Locating and Paying Participants

e_Form721T Tax Election for Payment Not Eligible for Rollover

Locating and Paying Participants

OMB: 1212-0055

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Tax Election for Payment Not Eligible for Rollover


PBGC Form 721T


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: 01/14/2021



Date of Plan Termination: FX.PrismCase.DOPT.XF



INSTRUCTIONS: Use this form to tell PBGC how much federal income tax to withhold from your payment. Please print clearly with blue or black ink.

Estate Representative: Use the deceased payee’s name, social security number or the estate’s employer identification number (EIN) in section 1.




1. Information about you or the estate

Last Name

First Name


Middle Name

Your Relationship to Deceased Payee (if applicable)


Social Security Number

Date of Birth (N/A, if estate)





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Mailing Address

Apartment / Route Number

City

State

Zip Code


Daytime Phone

Extension

Evening Phone

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x





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2. 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.



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Tax Election for Payment Not Eligible for Rollover

Form 721T, page 2 of 2


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF






3. 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








File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePayee Information Form_PBGC Form XXX
AuthorPBGC User
File Modified0000-00-00
File Created2021-01-14

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