Pbgc Form 705 - Beneficiary Application For Pension Benefits

Pbgc Form 705 - Beneficiary Application For Pension Benefits - 2006 Page 2

Beneficiary Application for Pension Benefits

Form 705, page 2 of 4

Plan Number:

Participant Name / SSN:

Applicant Name / SSN:

Your relationship to person who participated in the plan:

MARK ONLY ONE

A. Beneficiary - The benefits are from the pension plan of someone who is deceased.

My relationship to the participant:

Spouse

Other:

Date of participant’s death:

(

)

PROOF 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:

2. Signature

– You must 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

3. Information on Federal tax withholding –

Tax laws require that we withhold Federal income tax from

your pension payments unless you instruct us to do otherwise. You have three choices. Please read them

carefully and make your selection on the next page. You may choose:

A) To have PBGC withhold no Federal income taxes from your payments (not available if you live outside of the

United States).

B) To have PBGC follow IRS guidance and calculate your withholding.

If you choose this option, you need to tell us if you’re married and the number of allowances you claim. It is

possible that we will not withhold any Federal income tax even if you choose this option – if, for example, your

benefit is low or if you claim a large number of allowances. You may increase the amount we withhold by

claiming fewer allowances, by having additional money withheld, or by electing option C, below.

C) To have PBGC withhold the amount you tell us to withhold each month.

If you decide not to have PBGC withhold taxes or the amount that we withhold is too low, you may have to pay an

estimated tax directly to the Internal Revenue Service. If the amount of your estimated tax or your withholding is

too low, you may also have to pay the IRS penalties. You may wish to consult a tax specialist or the IRS about

your decision.

CONTINUE

Pbgc Form 705 - Beneficiary Application For Pension Benefits - 2006 Page 2