Form 721 Application for Eligible Rollover Payment – Non-Spouse B

Application for Eligible Rollover Payment
– Non-Spouse Beneficiary
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

PBGC Form 721

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

INSTRUCTIONS: Use this form to request a lump-sum payment if you are the beneficiary of a participant who has
died and you are not the spouse. Please enclose a legible copy of the death certificate unless you have already
sent a copy to PBGC. Please print clearly with blue or black ink.

1. Information about you
Last Name

First Name

Middle Name

Your Relationship to Deceased Payee

Social Security Number

Date of Birth

-

/

-

/

Mailing Address

Apartment / Route Number

City

State

Daytime Phone

(

Extension

)

-

x

CONTINUE ON BACK

Zip Code

Evening Phone

(

)

-

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Approved OMB 1212-0055
Expires __/__/2027

Application for Eligible Rollover Payment – Non-Spouse Beneficiary
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 721, page 2 of 4

Participant Name: FX.PrismCust.FullName.XF

2. Payment Option – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments.
Be sure you understand the tax implications of having PBGC send your lump-sum payment directly to you or to
an inherited individual retirement account (IRA).
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. Rollover my payment into an Inherited IRA – Send my entire payment, plus
interest, directly to the inherited (IRA) I designate. I understand that PBGC will not
withhold federal income tax from the payment.



B. Pay me directly - Send the entire payment, plus interest, directly to me. I
understand that I cannot rollover this amount later to an inherited IRA, and that
PBGC will withhold 20% of the taxable amount of this payment for federal income
tax.



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



C. Split my payment - Send some of the money directly to me, and send
some directly to an IRA as follows:
1. Send this much directly to me:

$

.

$

.

I understand that I cannot rollover this amount later to an inherited IRA
and that PBGC will withhold 20% of the taxable amount of this payment
for federal income tax.
*Complete Section D if you want the payment to be sent directly to your
bank account.
2. Send this much to an inherited IRA.
I understand that PBGC will not withhold taxes from this part of my
payment to the IRA I designate.
Note: the amount must be at least $500.00.

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 3. PLEASE SIGN THE FORM ON PAGE 4.

CONTINUE

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Application for Eligible Rollover Payment – Non-Spouse Beneficiary
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 721, page 3 of 4

Participant Name: FX.PrismCust.FullName.XF

D. Direct Payment Information Only. Complete this section to send your payment directly to your bank.
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. Information About Your Inherited Individual Retirement Account
Name of Receiving Account (example – Tom Smith as beneficiary of John Smith)

Account Number

Name of the Institution / Trustee

Daytime Phone

(

)

-

Mailing Address

City

State

Zip Code

CONTINUE ON BACK

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Application for Eligible Rollover Payment – Non-Spouse Beneficiary
Plan Number: FX.PrismCase.CaseIdNmbr.XF

Form 721, page 4 of 4

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