Form 700 Participant Application for Pension Benefits

Participant Application for Pension Benefits

PBGC Form 700

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:

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
6. Date of Birth MM/DD/YYYY
PROOF REQUIRED

5. Social Security Number
1

2

3

-

5

5

-

6

7

8

9

M M

/

D

D

/

Y

8. Mailing Address

Apartment / Route Number

City

State

Y

7. Gender
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
Are you currently married?
 YES
 NO
Enter spouse information as of the date you are completing this application.
Spouse Last Name

Spouse First Name

Spouse Middle Name

Other Last Name(s) used

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Spouse Social Security Number
1

2

3

-

5

5

Date of Marriage
MM/DD/YYYY
PROOF REQUIRED

-

6

M M

Spouse Date of Birth
7

8

9

/

D

D

M M

/

Y

Y

Y

/

D

D

MM/DD/YYYY PROOF REQUIRED
/

Y

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)?
 YES  NO
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. Annuity Starting Date

Month

Enter the Annuity Starting Date from your Retirement
Benefit Estimate. This is the date you would like your
payments to begin.

M

Year
M

/

Y

Y

Y

Y

If you would like a different Annuity Starting Date,
request a new retirement benefit estimate.
16. Working Retirement Restrictions
If the Annuity Starting Date you entered in Block 15 is on or after June 1, 2021, skip Block 16.
If the Annuity Starting Date you entered in Block 15 is before June 1, 2021, were you employed on that date?  YES  NO
If Yes, complete the following.
Employer Name
City
State
If you were employed by the company that sponsored your pension plan on the Annuity Starting Date, contact PBGC
to confirm your eligibility before submitting this application.
17. Election of Benefit Form
Before you choose an option below, please review the Summary of Examples in Your Benefit, Your Choice (enclosed
with this application). The summary provides an example of each option.

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Refer to the Retirement Benefit Estimate based on the Annuity Starting Date (Block 15) included in your package that
shows the amount of your benefit under the benefit forms below and your beneficiary choice.
Any cross-outs or changes in this section will require a new form.

NOTE: You cannot change your benefit election (marked below) after PBGC makes the first payment to you.
Benefit Form

My Choice
MARK ONLY ONE

A. Plan’s Automatic Form for an Unmarried Participant
If this is a straight life annuity do NOT complete Blocks 18a/18b.
If this is NOT a straight life annuity you must complete Block 18b.
B. Plan’s Automatic Form for a Married Participant
Complete Block 18a to select your spouse (from Block 13) as your beneficiary.
C. Straight Life Annuity
Do NOT complete Blocks 18a/18b.
If selecting Options D – G below you must also complete Block 18a.
D. Joint-and-50% Survivor Annuity
E. Joint-and-75% Survivor Annuity
F. Joint-and-100% Survivor Annuity
G. Joint-and-50% Survivor “Pop-up” Annuity
If selecting Options H – J below you must also complete Block 18b.
H. 5-year Certain-and-Continuous Annuity
(The 5-year Certain payment period starts on Annuity Starting Date in Block 15)
I. 10-year Certain-and-Continuous Annuity
(The 10-year Certain payment period starts on Annuity Starting Date in Block 15)
J. 15-year Certain-and-Continuous Annuity
(The 15-year Certain payment period starts on Annuity Starting Date in Block 15)
18a. Designation of Beneficiary for Survivor Annuity
Complete this section if you elected Benefit Forms D-G above.
Because you elected a joint-and-survivor annuity, your survivor annuity beneficiary designation is final and cannot be
changed after PBGC makes your first payment.
The beneficiary identified below will receive the survivor annuity that continues after your death and any additional
money owed to you at your death.
If your survivor annuity beneficiary predeceases you, no continuing survivor annuity is payable. If we owe you any
money at the time of your death (for example missed pension checks or any underpayments), we will pay a
beneficiary designated on Form 707.
Ensure your choice of beneficiary is consistent with your retirement estimate provided. Any changes require a new
retirement estimate.

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

Spouse (Identified in Block 13)
OR



Other Beneficiary

Beneficiary Last Name

Beneficiary First Name

Beneficiary Middle Name

Other Last Name(s) used

Beneficiary relationship to you
Beneficiary Social Security Number
1

2

3

-

5

5

-

6

7

Beneficiary Date of Birth
8

M

9

M

/

D

D

/

MM/DD/YYYY

Y

Beneficiary Mailing Address

Apartment / Route Number

City

State

Y

Y

Proof Required

Y

Zip Code/Postal Code

Country
Beneficiary Primary Phone
(

5

5

5

)

3

4

Beneficiary Secondary Phone
5

-

6

7

8

9

(

5

5

5

)

3

4

5

-

6

7

8

9

18b. Designation of Beneficiary for Certain-and-Continuous Annuity
Complete this section if you elected Benefit Forms H-J above.
Because you elected a Certain and Continuous Annuity you may change your beneficiary identified below at any time
by filing PBGC Form 711.
If you die before your certain period has expired the beneficiary identified below will receive benefits that continue
after your death and any additional money owed to you at your death.
If you die after your certain period has expired and we owe you any money at the time of your death (for example
missed pension checks or any underpayments), we will pay a beneficiary designated on Form 707.

Name your beneficiary below. You may name more than one beneficiary. State the percentage you want each one to receive,
and make sure the percentages total 100%. If you do not state percentages that total 100%, the amount owed will be
distributed equally among all beneficiaries.
To name more than two beneficiaries, list their names, dates of birth, Social Security numbers, contact information, and
percentages on a separate sheet of paper. Sign the sheet and attach it to this form.
 Check here if additional sheet is attached.
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.

Spouse (Identified in Block 13)

___________

%

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Beneficiary (1)

___________

%

Beneficiary (2)

___________

%

Total of percentages may
not exceed 100% for all
beneficiary entries

Beneficiary (1)
Beneficiary Last Name

Beneficiary First Name

Beneficiary Middle Name

Other Last Name(s) used

Beneficiary relationship to you
Beneficiary Social Security Number
1

2

3

-

5

5

-

6

7

Beneficiary Date of Birth
8

M

9

M

/

D

D

/

Y

Beneficiary Mailing Address

Apartment / Route Number

City

State

MM/DD/YYYY
Y

Y

Y

Zip Code

Country
Beneficiary Primary Phone
(

5

5

5

)

3

4

Beneficiary Secondary Phone
5

-

6

7

8

9

(

5

5

5

)

3

4

5

-

6

7

8

9

8

9

Beneficiary (2)
Beneficiary Last Name

Beneficiary First Name

Beneficiary Middle Name

Other Last Name(s) used

Beneficiary relationship to you
Beneficiary Social Security Number
1

2

3

-

5

5

-

6

7

Beneficiary Date of Birth
8

M

9

M

/

D

D

/

Y

Beneficiary Mailing Address

Apartment / Route Number

City

State

MM/DD/YYYY
Y

Y

Y

Zip Code

Country
Beneficiary Primary Phone
(

5

5

5

)

3

4

Beneficiary Secondary Phone
5

-

6

7

8

9

(

5

5

5

)

3

4

5

-

6

7

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Section 3: Spousal Consent to Elected Form of Benefit and Beneficiary
Leave this section blank if you:
•
are not married.
•
are married and chose Benefit Form B (Block 17) and a prospective Annuity Starting Date (on or after the date you contacted us to
begin receiving benefits) in Block 15.
Your spouse must consent by signing and notarizing the block below if you:
•
are married and did NOT choose Benefit Form B (Block 17)
•
chose a retroactive starting date in Block 15
Your spouse’s signature for the consent must be notarized by a notary public.
If your spouse does not consent, PBGC will pay your benefit in the normal married form.
To be completed by spouse:
By signing below, I consent to my spouse’s election of the benefit form selected in Block 17 and the beneficiary designated in Block 18. If my
spouse is offered a retroactive annuity starting date, I consent to my spouse’s election of the retroactive annuity starting date in Block 15. My
consent is voluntary. I have read and I understand the information provided with this application.
I understand all the following:
•

I have a right not to consent to my spouse’s election.

•

If I do not consent and my spouse chose a prospective annuity starting date in Block 15, my spouse’s benefit will be paid in the
plan’s automatic form for married participants, Benefit Form Choice B in Block 17. Under that automatic form, if my spouse dies
before me, I will receive a benefit equal to at least 50% of my spouse’s benefit for the rest of my life.

•

If I do not consent and my spouse chose a retroactive annuity starting date in Block 15, PBGC will not process this application.

•

If I do consent to my spouse’s election, survivor benefits, if any, will be paid according to the benefit form and beneficiary designation
elected by my spouse. As a result, if my spouse dies before me, I may not be entitled to any survivor benefits.

•

If my spouse elects a certain and continuous annuity (Choice H, I, or J in Block 17), and if I consent to this election, my spouse can
NOT make future changes to the beneficiary without my consent.

•

If my spouse chose a retroactive annuity starting date in Block 15, the survivor annuity may be less valuable (that is, my monthly
payment as a surviving beneficiary would be smaller) than the one available under a prospective annuity starting date.

•

If I do consent to my spouse’s election, I cannot revoke my consent after PBGC makes the first payment to my spouse.

________________________________________
SPOUSE’S SIGNATURE (MUST BE NOTARIZED)

_______________________________________
DATE

To be completed by Notary Public:
On this _____________ day of __________ Month, _______Year,
I acknowledge that this Spousal Consent to Elected Form of Benefit and Beneficiary 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: Method of Receiving Benefit Payments
PBGC pays benefits through safe, secure, and convenient electronic funds transfer. You will get your payment on time even if
you are out-of-town or unable to get to the bank.
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If you have a bank account, you can ask us to deposit your benefit payments to your account through Electronic Direct Deposit
(EDD).
Note: PBGC does not transfer funds to financial institutions outside the United States and its territories. If you live outside the
United States or its territories and do not have a U.S bank account, PBGC will send your payment to your mailing address.
19. How would you like to receive your payments?

A. By EDD to the account identified below, which must be titled in my name although it
is fine for there to be joint or other co-owners on the account.

My Choice
MARK ONLY ONE


B. By mail to my home address, which is printed in Section 1 of this form.



20. Financial Institution Information
Provide the information below for PBGC to send your payment directly to a financial institution. The information is available
from your financial institution or can be found on your checks and account statements. The sample check below shows the
location of your nine-digit routing number and your account number. If you are unsure of the routing number or your account
number, contact your financial institution.
You can cancel or change this arrangement by calling
PBGC at 1-800-400-7242. The financial institution can
cancel it by sending you a written notice.

Or Attach a VOIDED check to this application.

Do not complete below if VOIDED check is attached to this application.
Name(s) on the Account
(Your name must be on the account):
Routing Number:

Account Number – Numbers only:

Account Type
Checking

Savings





Section 5: Federal Tax Election
Complete this section by selecting only one option – A or B or C.
If you live outside the United States, you cannot select Option A. For additional guidance regarding these options and federal
tax withholding, please read page 4 of the enclosure: Your Benefit, Your Choice.
In general, tax laws require PBGC to withhold federal income tax from your pension payments unless you specifically elect not to
have taxes withheld.

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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 as if you were a married individual with three allowances.
This means that for the year 2021 we will withhold taxes only if your monthly PBGC benefit is $2,1.00 or more.

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 6: 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

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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 OR PROOF DOCUMENT COULD DELAY YOUR FIRST PAYMENT.
1. Did you sign and date the application in Section 6?
2. Did you enclose a copy of your proof of age document? Your driver’s license is not a proof of age
document.
3. If you are married, did you enclose a copy of your marriage certificate?
4. If you completed Section 18a and selected “Other Beneficiary”, did you enclose beneficiary proof of age?
5. If you are married, did you enclose a copy of your spouse’s proof of age?
6. If you are married and elected a benefit form other than option B in Block 17, did your spouse sign
Section 3 and was the signature notarized?
7. Did you elect only one option regarding federal tax withholding and is the election complete?

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