Form 700RN Election of Retroactive Annuity Starting Date (Spousal C

Election of Retroactive Annuity Starting Date
(Spousal Consent not Required)

PBGC Form 700RN

Pension Benefit Guaranty Corporation
For Assistance Call 1-800-400-7242
If you are deaf, hard of hearing, or have a speech disability, please dial 7-1-1 to access telecommunications relay services.
Participant Name:
Plan Number:
Date Printed:
Date of Plan Termination:

Use this form to elect a Retroactive Annuity Starting Date offered by PBGC, if:
• You were not married when you began receiving a benefit from this pension plan;
OR
•
You were married when you began receiving a benefit from this pension plan, and
o Your spouse is deceased; or
o PBGC has advised your spouse’s consent is not required for this election.
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
3. Middle Name
5. Social Security Number

2. First Name
4. Other Last Name(s) used
6. Date of Birth
/

MM/DD/YYYY

 MALE
 FEMALE

/

8. Mailing Address

Apartment / Route Number

City

State

7. Gender

Zip Code

Country
9. Primary Phone
(
11. Secondary Phone
(

10. Phone Type
 Home
 Mobile
12. Phone Type
 Home
 Mobile

13. Marital Status
Were you married when you began receiving a benefit from this pension plan?
 YES  NO

If YES, enter spouse information as of the date you began receiving a benefit from this pension plan.

Spouse Last Name

Spouse First Name

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Plan Number:
Participant Name:
Spouse Middle Name

Other Last Name(s) used

Spouse Social Security Number

Spouse Date of Birth
/

Date of Marriage
MM/DD/YYYY

/

/

Spouse Date of
Death (If applicable)
MM/DD/YYYY

/

/

MM/DD/YYYY
/

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

/

/

Name of alternate payee
Relationship to you

Section 2: Retirement Benefit Choices
Month

15. Retroactive Annuity Starting Date
Enter the Retroactive Annuity Starting Date you are
electing.

Year
/

16. Working Retirement Restrictions
If the Retroactive Annuity Starting Date you entered in Block 15 is on or after June 1, 2021, skip Block 16.
If the Retroactive 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 Retroactive Annuity Starting Date,
contact PBGC to confirm your eligibility before submitting this application.
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Plan Number:
Participant Name:

Section 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 the information I have provided on this form is true and correct.
_______________________________________
Participant Signature

_________________________________________
Date

Please complete this optional checklist below to ensure that your application form has all the required signatures and proof
documents before you submit it. A MISSING SIGNATURE COULD DELAY YOUR FIRST PAYMENT.
1. Did you sign and date the application in Section 3?
2. If you want to change your federal tax withholding, did you complete and submit IRS Form W-4P.

Approved OMB 1212-0055
Expires __/__/2027