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pdfParticipant Application for Pension Benefits
PBGC Form 700
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:
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
2. First Name
3. Middle Name
4. Other Last Name(s) used
5. Social Security Number
6. Date of Birth
MM/DD/YYYY
/
-
-
PROOF REQUIRED
/
8. Mailing Address
Apartment / Route Number
City
State
7. Gender
MALE
FEMALE
Zip Code
Country
9. Primary Phone
(
)
10. Phone Type
-
11. Secondary Phone
(
)
Home
Mobile
12. Phone Type
-
Home
Mobile
13. Marital Status
Are you currently married?
YES
NO
Enter spouse information as of the date you are completing this application.
Spouse Last Name
Spouse First Name
Spouse Middle Name
Other Last Name(s) used
Plan Number:
Participant Name:
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Spouse Social Security Number
-
Spouse Date of Birth
/
-
Date of Marriage
MM/DD/YYYY
PROOF REQUIRED
/
MM/DD/YYYY PROOF REQUIRED
/
/
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 an additional sheet is attached.
Date of Court Order
MM/DD/YYYY
/
/
Name of alternate payee
Relationship to you
Section 2: Retirement Benefit Choices
15. Annuity Starting Date
Month
Enter the Annuity Starting Date from your Retirement
Benefit Estimate. This is the date you would like your
payments to begin.
Year
/
If you would like a different Annuity Starting Date,
request a new Retirement Benefit Estimate.
16. Working Retirement Restrictions
If the Annuity Starting Date you entered in Block 15 is on or after June 1, 2021, skip Block 16.
If the 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 Annuity Starting Date, contact PBGC
to confirm your eligibility before submitting this application.
Plan Number:
Participant Name:
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17. Election of Benefit Form
Before you choose an option below, please review the Summary of Examples in Your Benefit, Your Choice (enclosed
with this application). The summary provides an example of each option.
Refer to the Retirement Benefit Estimate based on the Annuity Starting Date (Block 15) included in your package that
shows the amount of your benefit under the benefit forms below and your beneficiary choice.
Any cross-outs or changes in this section will require a new form.
NOTE: You cannot change your benefit form election (marked below) after PBGC makes the first payment to you.
Benefit Form
My Choice
MARK ONLY ONE
A. Plan’s Automatic Form for an Unmarried Participant
• If this is a straight life annuity do NOT complete Blocks 18a/18b.
• If this is NOT a straight life annuity you must complete Block 18b.
B. Plan’s Automatic Form for a Married Participant
Complete Block 18a to select your spouse (from Block 13) as your beneficiary.
C. Straight Life Annuity
Do NOT complete Blocks 18a/18b.
If selecting Options D – G below you must also complete Block 18a.
D. Joint-and-50% Survivor Annuity
E. Joint-and-75% Survivor Annuity
F. Joint-and-100% Survivor Annuity
G. Joint-and-50% Survivor “Pop-up” Annuity
If selecting Options H – J below you must also complete Block 18b.
H. 5-year Certain-and-Continuous Annuity
(The 5-year Certain payment period starts on Annuity Starting Date in Block 15)
I. 10-year Certain-and-Continuous Annuity
(The 10-year Certain payment period starts on Annuity Starting Date in Block 15)
J. 15-year Certain-and-Continuous Annuity
(The 15-year Certain payment period starts on Annuity Starting Date in Block 15)
18a. Designation of Beneficiary for Survivor Annuity
Complete this section if you elected Benefit Forms D-G above.
Because you elected a joint-and-survivor annuity, your survivor annuity beneficiary designation is final and cannot be
changed after PBGC makes your first payment.
The beneficiary identified below will receive the survivor annuity that continues after your death and any additional
money owed to you at your death.
Ensure your choice of survivor annuity beneficiary is consistent with the information in your Retirement Benefit
Estimate (name, date of birth). Any changes require a new Retirement Benefit Estimate.
If your survivor annuity beneficiary predeceases you, no continuing survivor annuity is payable. If we owe you any
money at the time of your death (for example missed pension checks or any underpayments), we will pay the
beneficiary(ies) you designate in Section 4.
Plan Number:
Participant Name:
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Spouse (Identified in Block 13)
OR
Other Beneficiary
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
-
Beneficiary Date of Birth
/
-
MM/DD/YYYY
Proof Required
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Zip Code/Postal Code
Country
Beneficiary Primary Phone
(
)
Beneficiary Secondary Phone
-
(
)
-
18b. Designation of Beneficiary for Certain-and-Continuous Annuity
Complete this section if you elected Benefit Forms H-J above.
Because you elected a Certain and Continuous Annuity you may change your beneficiary identified below at any time
by filing PBGC Form 711 Change of Beneficiary for Certain & Continuous (C&C) Benefits Only.
If you die before your certain period has expired the beneficiary identified below will receive benefits that continue
after your death and any additional money owed to you at your death.
If you die after your certain period has expired and we owe you any money at the time of your death (for example
missed pension checks or any underpayments), we will pay the beneficiary(ies) designated on Section 4.
Name your beneficiary below. You may name more than one beneficiary. State the percentage you want each one to receive,
and make sure the percentages total 100%. If you do not state percentages that total 100%, the amount owed will be
distributed equally among all beneficiaries.
To name more than two beneficiaries, list their names, dates of birth, Social Security numbers, contact information, and
percentages on a separate sheet of paper. Sign the sheet and attach it to this form.
Check here if an additional sheet is attached.
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.
Spouse (Identified in Block 13)
___________
%
Beneficiary (1)
___________
%
Beneficiary (2)
___________
%
Plan Number:
Participant Name:
4
Total of percentages may
not exceed 100% for all
beneficiary entries
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Beneficiary (1)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
-
Beneficiary Date of Birth
/
-
MM/DD/YYYY
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Beneficiary Primary Phone
(
)
Beneficiary Secondary Phone
-
(
)
-
Beneficiary (2)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
-
Beneficiary Date of Birth
/
-
MM/DD/YYYY
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Beneficiary Primary Phone
(
)
Plan Number:
Participant Name:
Beneficiary Secondary Phone
-
(
)
5
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Section 3: Spousal Consent to Elected Form of Benefit and Beneficiary
Leave this section blank if you:
•
are not married.
•
are married and chose Benefit Form B (Block 17) and a prospective Annuity Starting Date (on or after the date you contacted us to
begin receiving benefits) in Block 15.
Your spouse must consent by signing and notarizing the block below if you:
•
are married and did NOT choose Benefit Form B (Block 17)
•
chose a retroactive starting date in Block 15
Your spouse’s signature for the consent must be notarized by a notary public.
If your spouse does not consent, PBGC will pay your benefit in the normal married form.
To be completed by spouse:
By signing below, I consent to my spouse’s election of the benefit form selected in Block 17 and the beneficiary designated in Block 18. If
my spouse is offered a retroactive annuity starting date, I consent to my spouse’s election of the retroactive annuity starting date in Block
15. My consent is voluntary. I have read and I understand the information provided with this application.
I understand all the following:
•
I have a right not to consent to my spouse’s election.
•
If I do not consent and my spouse chose a prospective annuity starting date in Block 15, my spouse’s benefit will be paid in the
plan’s automatic form for married participants, Benefit Form Choice B in Block 17. Under that automatic form, if my spouse dies
before me, I will receive a benefit equal to at least 50% of my spouse’s benefit for the rest of my life.
•
If I do not consent and my spouse chose a retroactive annuity starting date in Block 15, PBGC will not process this application.
•
If I do consent to my spouse’s election, survivor benefits, if any, will be paid according to the benefit form and beneficiary
designation elected by my spouse. As a result, if my spouse dies before me, I may not be entitled to any survivor benefits.
•
If my spouse elects a certain and continuous annuity (Choice H, I, or J in Block 17), and if I consent to this election, my spouse can
NOT make future changes to the beneficiary without my consent.
•
If my spouse chose a retroactive annuity starting date in Block 15, the survivor annuity may be less valuable (that is, my monthly
payment as a surviving beneficiary would be smaller) than the one available under a prospective annuity starting date.
•
If I do consent to my spouse’s election, I cannot revoke my consent after PBGC makes the first payment to my spouse.
________________________________________
_______________________________________
SPOUSE’S SIGNATURE (MUST BE NOTARIZED)
DATE
To be completed by Notary Public:
On this _____________ day of __________ Month, _______Year,
I acknowledge that this Spousal Consent to Elected Form of Benefit and Beneficiary was signed by _________________________, who
appeared personally before me, or whose identity or signature is personally known to me, or who has proved to me on the basis of
satisfactory evidence that he/she is the authorized signer of this form.
________________________
DATE MY COMMISSION EXPIRES
__________________________________
NOTARY PUBLIC NAME
________________________
CITY / COUNTY
__________________________________
STATE
Plan Number:
Participant Name:
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Section 4: Designation of Beneficiary for Payments Owed at Death
Everyone should complete this section.
PBGC may owe you money at the time of your death. Typically, this happens if your final benefit is higher than the estimated
benefit we had been paying. It may also happen if you have uncashed payments at the time of death.
•
If another person continues to receive your benefit after your death (as with a joint-and-survivor or certain-andcontinuous annuity), PBGC will pay any money owed to that person.
•
If there are no continuing benefits or the person designated to receive continuing benefits (in Block 18 a or b of
this form) dies before you, PBGC will pay any money owed you at the time of your death to the person(s) and/or
entity(ies) (such as a trust, church, estate or other organization) that you designate in this section.
If you do not make a designation, or if all the beneficiaries you designate below die before you, PBGC will pay the money in this
order to: your spouse, your children, your parents, your estate, or your next of kin.
To name more than three beneficiaries, list their names, dates of birth, relationship to you, Social Security numbers, contact
information, and percentages on a separate sheet of paper, with your name and customer ID. Sign and date the sheet and
attach it to this form.
Check here if an additional sheet is attached.
If a beneficiary dies before you, the amount owed will be distributed equally among the remaining beneficiaries.
If all beneficiaries die before you, the amount owed will be distributed equally among the remaining beneficiaries.
This designation replaces any previous designation and will only be effective when PBGC receives it.
Beneficiary (1)
___________ %
Beneficiary (2)
___________ %
Beneficiary (3)
___________ %
The amount owed will be distributed equally among beneficiaries unless
percentages are provided for each beneficiary, and they total 100%.
If a beneficiary dies before you, the amount owed will be distributed equally
among the remaining beneficiaries.
Beneficiary Information (1)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you:
Beneficiary Social Security Number
-
-
Beneficiary Date of Birth MM/DD/YYYY
/
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Beneficiary Primary Phone
(
)
-
Beneficiary Secondary Phone
(
)
-
Plan Number:
Participant Name:
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Beneficiary Information (2)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Date of Birth MM/DD/YYYY
/
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Beneficiary Social Security Number
-
-
Zip Code
Country
Beneficiary Primary Phone
(
)
-
Beneficiary Secondary Phone
(
)
-
Beneficiary Information (3)
Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Name
Other Last Name(s) used
Beneficiary relationship to you
Beneficiary Social Security Number
-
-
Beneficiary Date of Birth MM/DD/YYYY
/
/
Beneficiary Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Beneficiary Primary Phone
(
)
-
Beneficiary Secondary Phone
(
)
-
Section 5: Method of Receiving Benefit Payments
PBGC pays benefits through safe, secure, and convenient electronic funds transfer. You will get your payment on time even if
you are out-of-town or unable to get to the bank.
If you have a bank account, you can ask us to deposit your benefit payments to your account through Electronic Direct Deposit
(EDD).
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.
Plan Number:
Participant Name:
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19. How would you like to receive your payments?
A. By EDD to the account identified below, which must be titled in my name although it is fine
for there to be joint or other co-owners on the account.
My Choice
MARK ONLY ONE
B. By mail to my home address, which is printed in Section 1 of this form.
20. Bank or Financial Institution and Account Information
Provide the information below for PBGC to send your payment directly to your account at a bank or other 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 6: 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
Plan Number:
Participant Name:
_________________________________________
Date
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THIS OPTIONAL CHECKLIST IS FOR YOUR USE
Please review the checklist below to ensure that your application form has all the required signatures and proof documents
before you submit it. A MISSING SIGNATURE OR PROOF DOCUMENT COULD DELAY YOUR FIRST PAYMENT.
1. Did you sign and date the application in Section 6?
2. Did you enclose a copy of your proof of age document? Your driver’s license is not a proof of age
document.
3. If you are married, did you enclose a copy of your marriage certificate?
4. If you completed Section 18a and selected “Other Beneficiary”, did you enclose beneficiary proof of age?
5. If you are married, did you enclose a copy of your spouse’s proof of age?
6. If you are married and elected a benefit form other than option B in Block 17, did your spouse sign
Section 3 and was the signature notarized?
7. Did you complete Section 4 naming beneficiary(ies) for payments owed at death?
8. Did you complete and submit IRS Form W-4P to choose your federal tax withholding?
Plan Number:
Participant Name:
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| File Type | application/pdf |
| Author | Duncan Stacey |
| File Modified | 2024-04-12 |
| File Created | 2024-04-12 |