Form 720 Application for Lump-Sum Payment

Application for
Lump-Sum Payment

PBGC Form 720

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed: 07/07/2021
Date of Plan Termination: FX.PrismCase.DOPT.XF

For assistance, call 1-800-400-7242
Participant Name: FX.PrismCust.FullName.XF

INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a copy
of your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s spouse, enclose a
copy of your marriage certificate if you have not already sent it to us. Please make sure that proof documents
are legible before sending to PBGC. If you have questions about other documents we accept as proof, call our
Customer Contact Center at 1-800-400-7242. Print clearly with blue or black ink.

1. General information about you
Last Name

First Name

Middle Name

Other Last Name(s) Used

Social Security Number

Date of Birth (Copy of Proof Required)

-

-

/

Gender

/

Mailing Address

Apartment / Route Number

City

State

Country

Province

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

Extension

)

MALE

x

(

)

If you are the participant and worked after the date the plan terminated, what year did
you stop working for the employer who sponsored your pension plan?

Year



CONTINUE ON BACK

Approved OMB 1212-0055
Expires _________

Application for Lump-Sum Payment
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 720, page 2 of 3
Participant Name: FX.PrismCust.FullName.XF

2. Payment Election – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments.
Be sure you understand the tax implications of electing to have PBGC pay the lump sum directly to you or to
an individual retirement arrangement (IRA) or a qualified retirement plan.
Please elect only one option - A or B or C. If you do not elect an option or if you elect more than one
option, PBGC will pay you according to option B.
A. Roll over my payment to an IRA or a plan – Send my entire payment, plus
interest, directly to an IRA or a qualified retirement plan. I understand that PBGC
will not withhold taxes from my payment.



B. Pay me directly – Send the entire payment, plus interest, directly to me. I
understand that PBGC will withhold 20% of the taxable amount of my payment for
federal income tax.



*Complete Section E if you want the payment to be sent directly to your bank
account.



C. Split my payment - Send some of the money, plus interest, directly to me,
and send some directly to an IRA or a qualified retirement plan as follows:
1. Send this much directly to me:

$

.

$

.

I understand that PBGC will withhold 20% of the taxable amount for
federal income tax.
*Complete Section E if you want the payment to be sent directly to your
bank account.
2. Send this much to an IRA or a qualified retirement plan.
I understand that PBGC will not withhold taxes from this part of my
payment.
Note: the amount must be at least $500.

NO LESS THAN $500

*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.

If you elected option A or C, complete Section D on page 3. PLEASE SIGN THE FORM ON PAGE 3.



CONTINUE

Application for Lump-Sum Payment
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 720, page 3 of 3
Participant Name : FX.PrismCust.FullName.XF

Payment Election (Continued)
D. Rollover Information

Name of IRA or Plan:
Type of IRA or Plan:



Traditional IRA



Roth IRA



Qualified retirement plan

Account Number
Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address
City

State

Zip Code

E. Direct Payment Information Only. Complete this section to send your payment directly to
your bank.
All fields required
Name(s) on the Account (Your name must be on the account)

Routing Number*

Account Number – Numbers only

Account Type
Checking
Savings





*This nine-digit number is on the lower left side of your check.

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