Form 714 Withdrawal of Employee Contributions – Non-Spouse Benefi

Withdrawal of Employee Contributions – Non-Spouse Beneficiary

PBGC Form 714

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: FX.PrismCust.FullName.XF
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed:
Date of Plan Termination: FX.PrismCase.DOPT.XF

INSTRUCTIONS: Please read the cover letter and complete and return this form to have PBGC pay the pension plan
contributions of FX.PrismPart.FullName.XF, deceased, to you. If you have questions, call our Customer Contact Center at
1-800-400-7242. Please print clearly with black or blue ink.

Section 1: General Information About You
1. Last Name

2. First Name

3. Middle Name

4. Other Last Name(s) Used

5. Social Security Number

6. Date of Birth: MM/DD/YYY

-

/

-

/

7. Mailing Address

Apartment / Route Number

City

State

Zip Code

Country
8. Email Address
9. Primary Phone
(

)

10. Phone Type

11. Secondary Phone
(

)

Home
Mobile

-

12. Phone Type
Home
Mobile

-

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Withdrawal of Employee Contributions – Non-Spouse Beneficiary

PBGC Form 714

Section 2. Payment Election – Choose A or B or C or D.
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 employee contributions, plus interest, directly to you or to an inherited
individual retirement account (IRA).
Mark One



Select Option A or B or C or D.
If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.
Option A: Roll over my payment to an IRA or a plan
Send my entire payment, plus interest, directly to an IRA I designate. I understand that PBGC will not

withhold taxes from my payment.



Option B: Pay me directly
Send my entire payment, plus interest, directly to me. I understand that I cannot rollover this amount later to an
Inherited IRA, and that PBGC will withhold 20% of the taxable amount of my payment for federal income tax.
*Complete Section 4 if you want the payment to be sent directly to your bank account.



Option C: Split my payment
Send some of the money, plus interest, directly to me, and send some directly to the IRA I designate, 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 4 if you want the payment to be sent directly to your bank account.
2. Send this much to an Inherited IRA:
$

.

I understand that PBGC will not withhold taxes from this part of my payment.
Note: the amount must be at least $500.



Option D: Split my payment between Taxable and Non-taxable amounts
Send the non-taxable amount directly to me AND the taxable amount to an Inherited IRA I designate. I
understand that PBGC will not withhold federal income tax from either payment.
*Complete Section 4 if you want the non-taxable amount to be sent directly to your bank account.
*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 or D, complete Section 3.
PLEASE SIGN THE FORM ON PAGE 3.

Section 3 – Information about your Inherited IRA
Name of Receiving Account (Example Tom Smith as beneficiary for John Smith)
Account Number
Name of the Institution / Trustee
Daytime Phone
(

)

-

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Withdrawal of Employee Contributions – Non-Spouse Beneficiary

PBGC Form 714

Mailing Address
City

State

Zip Code
-

Section 4: Direct Payment Information Only.
Complete this section to send your payment directly to your account at a bank or 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 change this arrangement by filing a new Form
710 Application for Electronic Direct Deposit. You can
cancel this arrangement by notifying PBGC in
writing. 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: 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.
_________________________________________

_______________________

SIGNATURE OF SPOUSE

DATE

3

Approved OMB 1212-0055
Expires __ /__ /2027