Form 700RN Election of Retroactive Annuity Starting Date (Spousal C

Election of Retroactive Annuity Starting Date
(Spousal Consent not Required)

PBGC Form 700RN

Pension Benefit Guaranty Corporation
For Assistance Call 1-800-400-7242
TTY/ASCII (American Standard Code for Information Interchange) users, call the federal relay service toll-free at 1-800-877-8339 and ask to be connected to
1-800-400-7242.
Participant Name:
Plan Number:
Date Printed:
Date of Plan Termination:

Use this form to elect a Retroactive Annuity Starting Date offered by PBGC, if:
• You were not married when you began receiving a benefit from this pension plan;
OR
•
You were married when you began receiving a benefit from this pension plan, and
o Your spouse is deceased; or
o PBGC has advised your spouse’s consent is not required for this election.
Please print clearly with blue or black ink. You must complete all sections of this form.

Section 1: General Information About You
1. Last Name

2. First Name

3. Middle Name

4. Other Last Name(s) used

5. Social Security Number
1

2

3

-

5

5

-

6. Date of Birth
6

7

8

9

M M

/

D

7. Gender

MM/DD/YYYY
D

/

Y

8. Mailing Address

Apartment / Route Number

City

State

Y

Y

Y

 MALE
 FEMALE

Zip Code

Country
9. Primary Phone
(

5

5

5

)

10. Phone Type
3

4

5

-

6

7

8

9

11. Secondary Phone
(

5

5

5

)

3

 Home
 Mobile
12. Phone Type

4

5

-

6

7

8

9

 Home
 Mobile

13. Marital Status
Were you married when you began receiving a benefit from this pension plan?
 YES  NO

If YES, enter spouse information as of the date you began receiving a benefit from this pension plan.

Spouse Last Name

Spouse First Name

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Plan Number:
Participant Name:
Spouse Middle Name

Other Last Name(s) used

Spouse Social Security Number
1

2

3

-

5

5

-

6

Spouse Date of Birth
7

8

9

M M

Date of Marriage
MM/DD/YYYY

M M

/

D

D

/

Y

Y

Y

Y

Spouse Date of
Death (If applicable)
MM/DD/YYYY

M M

/

D

D

/

Y

Y

Y

Y

/

D

D

MM/DD/YYYY
/

Y

Y

Y

Y

14. Court order related to the participant’s benefit

Is there a court order (for example domestic relations order, divorce decree, child support order, etc.) that requires some or all
your benefit to be paid to spouse, former spouse, child or other dependent (called alternate payee)?
 NO
 YES
If YES complete the following. If additional space is needed attach a separate sheet.
 Check here if additional sheet is attached.
Date of Court Order
MM/DD/YYYY

M

M

/

D

D

/

Y

Y

Y

Y

Name of alternate payee
Relationship to you

Section 2: Retirement Benefit Choices
15. Retroactive Annuity Starting Date

Month

Enter the Retroactive Annuity Starting Date you are
electing.

M

16. Were you employed on your Retroactive Annuity
Starting Date?

Year
M

/

Y

Y

Y

Y

 YES
 NO

Employer Name
City

State

If you were employed by the company that sponsored your pension plan on the Retroactive Annuity Starting Date,
contact PBGC to confirm your eligibility before submitting this application. If you return to work for the company that
sponsored your pension plan, notify PBGC immediately.

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Plan Number:
Participant Name:

Section 3: Federal Tax Election
If you wish to change your federal tax withholding, complete this section by selecting only one option – A or B or C.
If you do not choose an option, if you choose multiple options or if the option you select is incomplete, we will withhold
federal income taxes according to your most recent federal tax withholding election on file.
In general, tax laws require PBGC to withhold federal income tax from your pension payments unless you specifically elect not to
have taxes withheld.
MARK ONLY
ONE
A.

I elect not to have federal income tax withheld. (Available to U.S. residents only.)

B.

I elect to have federal income tax withheld based on IRS instructions.
Single
Marital Status
(REQUIRED)
Number of withholding allowances (REQUIRED)

Married

Additional monthly amount to be withheld (optional): $
C.

.00

I elect to have the following amount withheld for federal income tax.
$

.00

OR _ ____ %

Section 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 the information I have provided on this form is true and correct.
_______________________________________
Participant Signature

_________________________________________
Date

Please complete the checklist below to ensure that your application form has all the required signatures and proof documents
before you submit it. A MISSING SIGNATURE COULD DELAY YOUR FIRST PAYMENT.
1. Did you sign and date the application in Section 4?
2. If you want to change your federal tax withholding in Section 3, did you elect only one option and is the
election complete?

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