Pbgc Form 719 - Election To Withhold Federal Income Tax From Periodic Payments
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2Election to Withhold Federal Income Tax
PBGC Form 719
Approved OMB 1212-0055
from Periodic Payments
Expires 4/30/06
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 Alexandria Virginia 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Date of Plan Termination:
INSTRUCTIONS: Use this form to tell PBGC how much Federal income tax to withhold from your monthly or
annual payment. Use dark ink and be sure to print clearly. If you have questions, call our Customer Contact
Center at 1-800-400-7242 for information.
1. General information about you
Last Name
First Name
Middle Name
Other Name(s) Used
Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Email (optional)
Daytime Phone
Evening Phone
E
XTENSION
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)
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x
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)
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Social Security Number
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2. Signature
– You must sign and date this form.
SIGNATURE
DATE
CONTINUE
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