Form 705 Beneficiary Application for Pension Benefits

Beneficiary Application
for Pension Benefits

PBGC Form 705

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: Please complete this form to ask PBGC to begin payments to you as (1) the beneficiary of a
deceased participant who died after retirement, or (2) an alternate payee under a shared payment Qualified
Domestic Relations Order (QDRO). For items marked "Proof Required" enclose a legible copy of the
appropriate document if you have not already sent it to us. If you have questions, call our Customer Contact
Center at 1-800-400-7242. Please 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

-

-

/

Sex

/

Mailing Address

Apartment / Route Number

City

State

Country

Email

Daytime Phone

(

Extension

)

-

x

MALE



FEMALE



Zip Code

Evening Phone

(

)

-

Name of Plan Participant
MARK ONLY
ONE

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



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:

/



/



C. Other. Please explain:

CONTINUE ON BACK


Approved OMB 1212-0055
Expires 06/30/2027

Beneficiary Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 705, page 2 of 4

Participant Name : FX.PrismCust.FullName.XF

2. Designation of Beneficiary for payments owed at Death – If there are payments owed to you at the time
of your death, PBGC will pay them to the person(s) 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.
Beneficiary(ies)*

Social Security Number**

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.

3. Bank or Financial Institution Information
PBGC pays benefits through safe, secure and convenient electronic funds transfer to your bank account through Electronic
Direct Deposit (EDD).
Federal law mandates that all Federal benefit payments must be made electronically. If you do not have a bank account,
please consider creating one to receive your PBGC payment. You can find more information at FDIC: GetBanked.
(www.fdic.gov/getbanked)
If you are unable to create a bank account or do not have a U.S.-based bank account, contact our call center at
1-800-400-7242 for assistance. nternational callers from a landline, please call 202-326-4000, and press "0" for a
Customer Service Representative.
Attach a voided check to this application or fill in the following information off your check.
CONTINUE



Approved OMB 1212-0055
Expires 06/30/2027

Form 705, page 3 of 4

Beneficiary Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF

3. Bank or Financial Institution Information (continued)
All fields required
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



CONTINUE ON BACK




Approved OMB 1212-0055
Expires 06/30/2027

Form 705, page 4 of 4

Beneficiary Application for Pension Benefits
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF

4. 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 complete this optional 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 above?



2. If the participant is deceased, did you enclose a copy of the death certificate?





3. Did you enclose a copy of your marriage certificate or common law document, if applicable?
4. Did you complete and submit IRS Form W-4P to choose your federal tax withholding?

Approved OMB 1212-0055
Expires 06/30/2027