Form 706 Beneficiary Application for Pension Benefits - OF

Beneficiary Application
For Pension Benefits – OF

PBGC Form 706

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750
Plan Name:
Plan Number:
Date Printed:
Date of Plan Termination:

For assistance, call 1-800-400-7242
Participant Name :

INSTRUCTIONS: Please complete this form to ask PBGC to begin payments to you as (1) the beneficiary of a
deceased participant who died before retirement, or (2) an alternate payee under a separate interest Qualified
Domestic Relations Order (QDRO). For those items marked "Proof Required," enclose a copy of the
appropriate document if you have not already sent it to us. Acceptable documents for proof of age include
your birth or baptism certificate, or U.S. passport; for marriage, a marriage certificate. Please make sure that
proof documents are legible before sending to PBGC. If you have questions about other acceptable documents,
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

Email

Daytime Phone

(

EXTENSION

)

-

x

MALE

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FEMALE

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Zip Code

Evening Phone

(

)

Please enter your Annuity Starting Date (ASD) using the date from the Retirement
Benefit Estimate that provides the amounts of your benefit options.

/
MONTH

YEAR

Name of the plan participant:

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Beneficiary Application for Pension Benefits - OF
Plan Number:

Form 706, page 2 of 5

Participant Name:

MARK ONLY
ONE

Your relationship to the plan participant:
A. Beneficiary - The benefits are from the pension plan of someone who is deceased.

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Marriage Proof Required (Certificate or Common Law
document)

Date of participant’s death:

/

/

(Copy of Death
Certificate Required)

B. Alternate payee - I have a Qualified Domestic Relations Order (QDRO) that establishes my
right to receive some or all of a participant's benefits from a pension plan.

/

Date of QDRO:

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/

2. Election of Benefit Form – You may receive your benefit in one of the benefit forms listed below if you are
an Alternate Payee with a separate interest under a QDRO; you are entitled to a Qualified Preretirement Survivor
Annuity (QPSA) because your spouse died before retiring; or your former spouse granted you a QPSA under a
QDRO. Before you choose an option, please read the examples in Your Benefit, Your Choice attached to this
application and the calculations included in your package. The calculations show the amount you would receive
under each benefit form.
NOTE: You cannot change your benefit form election (marked below) after PBGC makes the first payment to you.
MARK ONLY ONE

Benefit Form
A. The form your plan would pay you automatically, if different from below

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B. 5-year Certain-and-Continuous Annuity

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(The 5-year Certain payment period starts on Annuity Starting Date in Section 1.)
C. 10-year Certain-and-Continuous Annuity
(The 10-year Certain payment period starts on Annuity Starting Date in Section 1.)
D. 15-year Certain-and-Continuous Annuity
(The 15-year Certain payment period starts on Annuity Starting Date in Section 1.)

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E. Straight Life Annuity

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Plan Number:

Form 706, page 3 of 5

Participant Name:

3. Designation of Beneficiary for payments owed at Death – PBGC will pay any money we owe you at
the time of your death and/or for the remaining period of a Certain & Continuous benefit to the person(s) and/or
entity(ies) (such as a trust, church, estate or other organization) that you designate below. 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.
Social Security
Number**

Beneficiary(ies)*

Date of Birth**

Relationship

Percentage***

Name ___________________________________
Address __________________________________
_________________________________________
Daytime Tel. No:_________________________

Name ___________________________________
Address __________________________________
_________________________________________
Daytime Tel. No:_________________________

Name ___________________________________
Address __________________________________
_________________________________________
Daytime Tel. No:_________________________

*To name more beneficiaries, please list them with requested contact info, DOB and SSN on an attached sheet with your signature.
**Complete if person.
*** Percentage(s) does not have to be provided.
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.

4. 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.
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Plan Number:

Form 706, page 4 of 5

Participant Name:

Method of receiving benefit payments (continued)
How would you like to receive your payments?

MARK ONLY
ONE

A. By EDD to the account identified below, which must have your name on it.

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B. By mail to my home address, which is printed in section 1 of this form. You may choose this
option if EDD would be difficult or a burden because:
• You do not have a bank account.
•

You reside in a remote locate that does not have the infrastructure to support electronic
fund transfers

•

It is too expensive for you to maintain a bank account

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Financial institution 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.

All fields required
Do not complete below if VOIDED check is attached to this application.
ALL Name(s) on the Account
(Your name must be on the account):
Routing Number

Account Number – Numbers only

Account Type
Checking
Savings

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Beneficiary Application for Pension Benefits - OF
Plan Number:

Form 706, page 5 of 5

Participant Name:

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 of the information I have provided on this form is true and correct.

SIGNATURE

DATE

Please review this optional checklist 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?
2. Did you enclose a copy of your proof of age document? Your driver’s license is not a proof document.
3. Did you enclose a copy of the participant’s death certificate, if applicable?
4. Did you enclose a copy of your marriage certificate or common law document, if applicable?
5. Did you complete and submit IRS Form W-4P to choose your federal tax withholding?

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