Form 721T Tax Election for Payment Not Eligible for Rollover

Application for Payment Not Eligible for
Rollover
Pension Benefit Guaranty Corporation.
P.O. Box 151750 Alexandria Virginia 22315-1750

PBGC Form 721T

For assistance, call 1-800-400-7242

Plan Name: FX.PrismCase.CaseTitle.XF
Plan Number: FX.PrismCase.CaseIdNmbr.XF
Date Printed:
Date of Plan Termination: FX.PrismCase.DOPT.XF

Participant Name: FX.PrismCust.FullName.XF

INSTRUCTIONS: Use this form to apply to PBGC for a one-time payment . Please print clearly with blue or
black ink.
Estate Representative: Use the deceased payee’s name, social security number or the estate’s employer
identification number (EIN) in section 1.

1. Information about you or the estate
Last Name

First Name

Middle Name

Your Relationship to Deceased Payee (if applicable)

Social Security Number

-

Date of Birth (N/A, if estate)
-

-

-

Mailing Address

Apartment / Route Number

City

State

Daytime Phone

(

Extension

)

-

x

Zip Code

Evening Phone

(

)

-

Section 2: 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. International 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.

Plan Number:
Participant Name:

Approved OMB 1212-0055
Expires 06/30/2027

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

Approved OMB 1212-0055
Expires 06/30/2027