Form 721T Tax Election for Payment Not Eligible for Rollover

Tax Election for Payment Not Eligible for
Rollover
Pension Benefit Guaranty Corporation.
P.O. Box 151750 Alexandria Virginia 22315-1750

PBGC Form 721T

For assistance, call 1-800-400-7242

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

Participant Name: FX.PrismCust.FullName.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)
-

-

-

Mailing Address

Apartment / Route Number

City

State

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

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.



CONTINUE ON BACK


Approved OMB 1212-0055
Expires ___________10/31/21

Tax Election for Payment Not Eligible for Rollover
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 721T, page 2 of 2

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