Form 718 Installment Payment Agreement

Installment Payment Agreement

Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed: 01/11/2021
Date of Plan Termination: FX.PrismCase.DOPT.XF

PBGC Form 718

Participant Name: FX.PrismCust.FullName.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

/

/

Mailing Address

Apartment / Route Number

City

State

Country

Email

Daytime Phone

(

Extension

)

-

x

MALE



FEMALE



Zip Code

Evening Phone

(

)

-

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 ________ 10/31/21

Installment Payment Agreement
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 718, page 2 of 2
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
____________________________________________
Printed Name of FOD Collections Official

___________________
Date