Form 703MP - Roth heading

Application for Elective Lump-Sum
Payment - Roth Account
Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

PBGC Form 703MP

For assistance, call 1-800-400-7242

Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed: 12/20/2022
Date of Plan Termination: FX.PrismCase.DOPT.XF

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

-

-

(PROOF REQUIRED)

/

Gender

/

Mailing Address

Apartment / Route Number

City

State

Country

Province

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

EXTENSION

)

MALE

x

(

)

Year

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?

2a. Marital status – Please complete both 2a. and 2b.
Are you currently married?

Yes



No



Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Last Name(s) Used

Spouse’s Social Security Number

-

-

Spouse’s Date of Birth

/

Date of Marriage (PROOF REQUIRED)

/

/

/

2b. 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 of your benefit be paid to a spouse, former
spouse, child, or other dependent?

Yes



No





CONTINUE ON BACK

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

3.

Form 703MP - Roth Account, page 2 of 6
Participant Name: FX.PrismCust.FullName.XF

Lump-sum payment election – If you are the participant, you and your spouse have to make an
important decision about how your benefit is paid.
Important Information about Your Benefit Choices

You need to decide whether you want to receive your benefit as a single lump-sum payment now or as a
monthly annuity benefit at some future date. If you are currently married and want a lump-sum payment, your
spouse’s consent is needed for PBGC to comply with your election.
If you complete this application and your spouse consents on the next page to your election, PBGC will pay
your entire benefit to you in a lump-sum. No future benefits will be payable to you or your spouse. If you would
prefer to receive your benefit in a monthly annuity form, call PBGC and do not submit this application.
Annuity Benefit Form

At the time that you are eligible to retire, PBGC will pay your benefit as an annuity, generally monthly, for your
life. The form of your annuity benefit will depend on your marital status at retirement. If you are married, you
will receive a joint-and-survivor benefit unless your spouse consents to your waiver of this form of benefit in
writing. The joint-and-survivor form provides a benefit for your life and, if you die before your spouse, at least
50% of your benefit amount will be paid to your spouse for the rest of your spouse’s life. To help pay for your
spouse's benefits, your payment will most likely be reduced. If your spouse consents to your waiver of the jointand-survivor benefit, or if you are not married, you may select from a number of PBGC optional benefit forms.
Lump-Sum Payment

You will receive a single payment now of your entire benefit. No future annuity benefits will be payable to you or
your spouse.
An example of your choices:

.

Lump-sum payment: Sam elects a lump-sum payment and Carol consents to it (Carol signs in front of
a notary public), and Sam receives $7,000 in the form of a single lump-sum benefit, with interest. No
future payments will be payable to Sam or Carol.

.

Joint-and-50% survivor annuity: Sam (age 65) and Carol (age 61) are married when Sam retires. Sam
receives a payment of $260 for the rest of his life. After Sam dies, Carol receives $130 a month for the
rest of her life. If Carol dies first, Sam will continue to receive $260 a month for the rest of his life.

.

Other annuity choices: If Sam waives a joint-and-survivor annuity when he retires, and Carol consents
to his waiver, other annuity benefit forms are available. To learn more about your specific annuity
benefit choices, call PBGC at 1-800-400-7242.



CONTINUE

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

Form 703MP - Roth Account, page 3 of 6
Participant Name: FX.PrismCust.FullName.XF

4. Spousal consent for a participant to receive an elective lump-sum benefit. If you are married
and want to receive your benefit in a lump sum or single payment, your spouse must complete this section.
Your spouse’s consent must be signed in the presence of or acknowledged by a notary public.
By signing below, I consent to my spouse's election to receive his/her benefit in a lump-sum or single
payment. My consent is voluntary. I have read and I understand the information provided with this application.
In particular, I understand all of the following:
•

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

•

If I do not consent, my spouse’s benefit will be paid in the plan’s automatic form for married participants. Under
that automatic form, if my spouse dies before me, I would receive a benefit equal to at least 50% of my spouse’s
benefit for the rest of my life.

•

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

SPOUSE’S SIGNATURE (MUST BE NOTARIZED)

DATE

Must be signed by a Notary Public

To be completed by Notary Public:

Subscribed and sworn to before me this __________________ day of ____________________, Year______

DATE MY COMMISSION EXPIRES

NOTARY PUBLIC NAME

CITY / COUNTY

STATE



CONTINUE ON BACK

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

Form 703MP - Roth Account, page 4 of 6
Participant Name: FX.PrismCust.FullName.XF

5. Payment Election – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments.
Be sure you understand the tax implications of having 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.
*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 selected option A or C, complete Section D on page 5.
PLEASE SIGN THE FORM ON PAGE 6.



CONTINUE

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

Form 703MP - for Roth Account, page 5 of 6
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.

CONTINUE ON BACK





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

Form 703MP - for Roth Account, page 6 of 6
Participant Name: FX.PrismCust.FullName.XF

6. Signature – Sign and date this application in the presence of or acknowledged by a Notary Public. 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

To be completed by Notary Public:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
DATE MY COMMISSION EXPIRES

NOTARY PUBLIC NAME

CITY / COUNTY

STATE