Form 720MP - Roth heading

Application for
Lump-Sum Payment - Roth Account
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:
Date of Plan Termination: FX.PrismCase.DOPT.XF

PBGC Form 720MP

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 8/31/2024

Application for Lump-Sum Payment – Roth Account

Form 720MP, page 2 of 4

Plan Number: FX.PrismCase.CaseIdNmbr.XF

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 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 elected option A or C, complete Section D on page 3.
PLEASE SIGN THE FORM ON PAGE 4.



CONTINUE

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

Form 720MP, page 3 of 4
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 Lump-Sum Payment - Roth Account
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 720MP, page 4 of 4
Participant Name : FX.PrismCust.FullName.XF

3. 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