Pbgc Form 720 - Application For Lump-Sum Payment
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1
2
3Application for
PBGC Form 720
Lump-Sum Payment
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 • Alexandria, VA 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Applicant Name / SSN:
Date of Plan Termination:
INSTRUCTIONS: Use this form to request a lump-sum payment. When "proof required" is indicated, please enclose
a copy of a birth or baptism certificate, or a U.S. Passport, whichever is appropriate, unless you already sent
PBGC a copy of this document. If you do not have these documents, contact our Customer Service Center at 1-
800-400-7242 for information about other acceptable documents. Be sure to print clearly and use dark ink.
1. General information about you
Last Name
First Name
Middle Name
Other Name
(
.
.,
)
E
G
MAIDEN NAME
Social Security Number
Date of Birth
Gender
�
(
)
PROOF REQUIRED
MALE
-
-
/
/
�
FEMALE
Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Province
Daytime Phone
Evening Phone
E
XTENSION
(
)
-
x
(
)
-
2.
Signature
– You must sign and date this application.
I declare under penalty of perjury that all of the information I have provided on this form is true and correct.
(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.)
SIGNATURE
DATE
If the total amount of your benefit, including interest, is less than $200, you only need to complete and return
this page. PBGC will pay your benefit directly to you and will not withhold any taxes from it, but the payment is
taxable income.
�
�
CONTINUE
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