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

Election of Retroactive Annuity Starting Date
(Spousal Consent Required)

PBGC Form 700RSC

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:

If you have been offered a retroactive annuity starting date and you were married when you began receiving a benefit
from this pension plan (and that spouse is still living), use this form to elect the retroactive annuity starting date.
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

Spouse Middle Name

Other Last Name(s) used

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Plan Number:
Participant Name:
Spouse Social Security Number
1

2

3

-

5

5

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

-

6

Spouse Date of Birth
M M

7

8

9

M M

/

D

D

/

Y

Y

Y

Y

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 you have more than one court order or alternate payee, list on a separate sheet and attach to
this application.
 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: Spousal Consent to Retroactive Annuity Starting Date
Leave this section blank if:
• you were not married when you started receiving benefit, or
• the spouse you were married to when you started receiving benefits is deceased.
If you were married when you began receiving benefits, your spouse at that time must consent to your choice by signing below.
•
His/her signature for the consent must be notarized by a notary public.
• Without his/her consent, your Annuity Starting Date will not change.
To be completed by the spouse who was married to the participant when he/she began receiving benefits:
By signing below, I consent to my spouse’s (or former spouse’s) election to change the annuity starting date to the Retroactive
Annuity Starting Date shown in the enclosed Retirement Benefit Estimate.
I affirm that I have read and understood the information provided by PBGC in the Retirement Benefit Estimate and that my
consent to this change is voluntary.
In addition, I understand that:
•

My consent is required to change the starting date of the annuity.

•

I have a right not to consent to the change in the starting date of the annuity.

•

With or without my consent, the annuity will continue to be paid in the form of benefit the participant originally
elected.

•

Any survivor benefits will be paid according to the form of benefit originally elected and to the designated beneficiary.

•

By agreeing to change the starting date to the Retroactive Annuity Starting Date, if the participant dies before me, my
monthly payment as surviving beneficiary (if applicable) will be smaller than if the starting date remained unchanged.

•

My signature below must be notarized.

•

Once I give my consent, I cannot revoke it.

_______________________________________________

_______________________________________

SIGNATURE OF SPOUSE WHO WAS MARRIED TO THE PARTICIPANT
WHEN HE/SHE BEGAN RECEIVING BENEFITS
(MUST BE NOTARIZED)

DATE

To be completed by Notary Public:
On this _____________ day of __________ Month, _______Year,
I acknowledge that this Spousal Consent to Retroactive Annuity Starting Date was signed by _________________________,
who appeared personally before me, or whose identity or signature is personally known to me, or who has proved to me on the
basis of satisfactory evidence that he/she is the authorized signer of this form.
________________________
DATE MY COMMISSION EXPIRES

__________________________________
NOTARY PUBLIC NAME

________________________
CITY / COUNTY

__________________________________
STATE

Section 4: Federal Tax Election

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Plan Number:
Participant Name:
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 5: 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 5?
2. If you were married when you started receiving benefits, did that spouse sign Section 3, and was the
signature notarized?
3. If you want to change your federal tax withholding, did you elect only one option in Section 4and is the
election complete?

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Expires _____