Form 713 Election to Withdraw Employee Contributions

Election to Withdraw Employee Contributions

PBGC Form 713

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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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 713

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. Please read
the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments before you make a withdrawal election and be sure
you understand the implications of withdrawing the contributions.
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: ______________________________ ________

3

Date: ____________________

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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: Payment Election
Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments and be sure you understand the tax
implications of electing to have PBGC pay the contributions 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 or D. If you do not elect an option or if you elect more than one option, PBGC will
pay you according to option B.
Mark One



Select Option A or B or C or D.
If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.
Payment Option 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.



Payment Option B: Pay me directly – Send my entire payment, plus interest, directly to me. I understand that
PBGC will withhold 20% of the taxable amount of this payment for federal income tax.
*Complete Section F if you want the payment to be sent directly to your bank account.



Payment Option 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 amount directly to me:
$

.

I understand that PBGC will withhold 20% of the taxable amount for federal income tax.
*Complete Section F if you want the payment to be sent directly to your bank account.
2. Send this amount 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.
Payment Option D: Split my payment - Split my payment between Taxable and Non-taxable amounts. Send
the non-taxable amount directly to me AND the taxable amount to an IRA or a qualified retirement plan.
I understand that PBGC will not withhold federal income tax from either payment.
*Complete Section 6 if you want the non-taxable amount to be sent directly to your bank account.
*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.

Section 5: Rollover Information
Complete this section if you are choosing any option that includes rollover (A or C or D)
Name of IRA or Plan:
Type of IRA or Plan (Check One below):





Traditional IRA
Roth IRA
Qualified Retirement Plan

Account Number:
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Name of Institution / Trustee

PBGC Form 713

Daytime Phone
(

)

-

Mailing Address
City

State

Zip Code
-

Section 6: Method of Receiving Direct Payments
Complete this section if you are choosing option B or D, unless you want us to mail the payment to your mailing address.
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:

_____________________________________

Account Type
Checking

Savings





Section 7: 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

Date
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