713RBD Election to Withdraw Employee Contributions, post RBD

Election to Withdraw Employee Contributions, post RBD

PBGC Form 713RBD

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 Name:
Plan Number:
Date Printed:
Date of Plan Termination:

INSTRUCTIONS: Complete this form to elect whether to withdraw contributions made to the above pension plan in a single
sum. Please read the cover letter and this form carefully before you make an election.
Please print clearly with blue or black ink.

Section 1: General Information About You
1. Last Name

2. First Name

3. Middle Name

4. Social Security Number
-

5. Mailing Address

Apartment / Route Number

City

State

Zip Code

Country
6. Email Address (optional)
7. Primary Phone
(

)

8. Phone Type
-

9. Secondary Phone
(

)

Home
Mobile
10. Phone Type

-

Home
Mobile

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Election to Withdraw Employee Contributions, post RBD

Mark
One



Your relationship to the person who participated in the plan:

Self- The benefits are from my pension plan.
I am: Married
My date of birth:



PBGC Form 713RBD

Not Married
MM/DD/YYY

/

/

Spouse - The benefits are from the pension plan of the participant who is deceased.
Participant’s name: __________________________________________________________________
Participant’s Social Security Number:
Participant Date of Birth: MM/DD/YYYY
/

/

Participant Date of Death: MM/DD/YYYY
/



/

Alternate payee - I have a court order that establishes my right to receive some or all of a participant’s
benefits from a pension plan.
Participant’s name: ___________________________________________________________________
Date of Order: MM/DD/YYYY
/

/

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Section 2. Withdrawal Election – Choose A or B.
You may withdraw the contributions any time before you retire or when you apply to start your pension benefits.
Option A – You can only elect this option if you are applying for pension benefits at this time.
Option B – You can elect this option to 1) withdraw your contributions before you retire or 2) withdraw your contributions when
you are applying for pension benefits.

Option A. Election Not To Withdraw Employee Contributions
If you are applying for pension benefits and do not want to withdraw your contributions in a single sum, check the
box and sign and date below.

 Election Not to Withdraw Employee Contributions
I am applying for pension benefits. I elect not to withdraw the employee contributions in a single sum and to receive my pension
which includes the amount derived from the employee contributions.
I understand that I cannot change this election after the date that my pension benefit payments begin.

If you elect Option A above, you need only sign below and return pages 1 through 3 of this form to PBGC.
Signature – Sign and date this form. 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: ______________________________ ________

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Date: ____________________

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PBGC Form 713RBD

Option B. Election to Withdraw Employee Contributions
If you want to withdraw the contributions (plus interest) in a single sum, check the box below and complete the remainder of
this form. If you are the participant and you are married, your spouse must complete section 3.

Election to Withdraw Employee Contributions
I elect to withdraw the contributions, plus interest, in a single sum. I understand that withdrawing the contributions now will
result in a smaller pension payment.
I understand that I cannot change this election after PBGC pays the contributions (plus interest) to me.
If you are married, go to Section 3; otherwise go to Section 4.

Section 3: Spouse’s consent for withdrawal of employee contributions
If you are the participant and you are married, your spouse’s consent must be signed in the presence of or acknowledged by a
notary public.

Spouse’s Last Name

Spouse’s First Name

Spouse’s Middle Name

Other Last Name(s) Used

Spouse’s Social Security Number

Date of Marriage

-

-

/

/

By signing below: (1) I consent to my spouse’s election to withdraw his or her pension contributions, plus interest,
in a single sum. (2) My consent is voluntary and I have a right not to consent to my spouse’s election. (3) I understand
that as a result of agreeing to the withdrawal of my spouse’s contributions in a single sum that any spousal benefit
that I may receive will be reduced. (4) I cannot revoke my consent after PBGC pays the contributions, plus interest,
to my spouse.

Spouse’s Signature: ________________________________

Date: ____________________

To be completed by Notary Public:
Subscribed and sworn to before me this __________________ day of ____________________, Year______
____________________________________
DATE MY COMMISSION EXPIRES

___________________________________
NOTARY PUBLIC NAME

____________________________________

___________________________________

CITY/COUNTY

STATE

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Section 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 payment to your account through Electronic Direct Deposit
(EDD).
Note: PBGC does not transfer funds to financial institutions outside the United States and its territories.
How would you like to receive your payment?
My Choice
MARK ONLY ONE
A. By EDD to the account identified below, which must be titled in my name although it is
fine for there to be a joint account or other co-owners on the account.



B.



By mail to my home address, which is printed in Section 1 of this form.

Section 5: Electronic Direct Deposit (EDD) Payment Information Only
Complete this section if you are choosing 4.A.
Account Information
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:

_____________________________________

5

Account Type
Checking

Savings





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PBGC Form 713RBD

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.

Signature: ______________________________ __________

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Date: ____________________

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