Form 720 Application for Lump-Sum Payment

Application for
Lump-Sum Payment

PBGC Form 720

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750
Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed:
Date of Plan Termination: FX.PrismCase.DOPT.XF

For assistance, call 1-800-400-7242
Participant Name: FX.PrismCust.FullName.XF

INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a
copy of your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s
spouse, enclose a copy of your marriage certificate if you have not already sent it to us. Please make
sure that proof documents are legible before sending to PBGC. If you have questions about other
documents we accept as proof, 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

Province

Daytime Phone

(

-



FEMALE



Zip Code

Evening Phone

Extension

)

MALE

x

(

)

If you are the participant and worked after the date the plan terminated, what year
did you stop working for the employer who sponsored your pension plan?

Year



CONTINUE ON BACK

Approved OMB 1212-0055
Expires __/__/2027

Application for Lump-Sum Payment
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 720, page 2 of 3
Participant Name: FX.PrismCust.FullName.XF

2. Payment Election – 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 lump sum
directly to you or to an individual retirement arrangement (IRA) or a qualified retirement plan.
Please elect only one option - A or B or C. If you do not elect an option or if you elect more than
one option, PBGC will pay you according to option B.
A. Roll over my payment to an IRA or a plan – Send my entire payment, plus
interest, directly to an IRA or a qualified retirement plan. I understand that PBGC
will not withhold taxes from my payment.



B. Pay me directly – Send the entire payment, plus interest, directly to me. I
understand that PBGC will withhold 20% of the taxable amount of my payment for
federal income tax.



*Complete Section E if you want the payment to be sent directly to your bank
account.



C. Split my payment - Send some of the money, plus interest, directly to me,
and send some directly to an IRA or a qualified retirement plan 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 E if you want the payment to be sent directly to your
bank account.
2. Send this much to an IRA or a qualified retirement plan.
I understand that PBGC will not withhold taxes from this part of my
payment.
Note: the amount must be at least $500.

NO LESS THAN $500

*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, complete Section D on page 3. PLEASE SIGN THE FORM ON PAGE 3.



CONTINUE

Application for Lump-Sum Payment
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 720, page 3 of 3
Participant Name : FX.PrismCust.FullName.XF

Payment Election (Continued)
D. Rollover Information

Name of IRA or Plan:
Type of IRA or Plan:



Traditional IRA



Roth IRA



Qualified retirement plan

Account Number
Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address
City

State

Zip Code

-

E. Direct Payment Information Only. Complete this section to send your payment directly to your bank.
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





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

SIGNATURE

DATE