Form 721T Tax Election for Payment Not Eligible for Rollover

Application for Payment Not Eligible for
Rollover
Pension Benefit Guaranty Corporation.
P.O. Box 151750 Alexandria Virginia 22315-1750

PBGC Form 721T

For assistance, call 1-800-400-7242

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

Participant Name: FX.PrismCust.FullName.XF

INSTRUCTIONS: Use this form to apply to PBGC for a one-time payment . Please print clearly with blue or
black ink.
Estate Representative: Use the deceased payee’s name, social security number or the estate’s employer
identification number (EIN) in section 1.

1. Information about you or the estate
Last Name

First Name

Middle Name

Your Relationship to Deceased Payee (if applicable)

Social Security Number

-

Date of Birth (N/A, if estate)
-

-

-

Mailing Address

Apartment / Route Number

City

State

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

2. 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

Approved OMB 1212-0055
Expires __/__/2027