Schedule SSA Annual Registration Statement Identifying Separated Part

SCHEDULE SSA
(Form 5500)

Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits

Official Use Only

OMB No. 1210-0110

2007

Under Section 6057(a) of the Internal Revenue Code

έ

File as an attachment to Form 5500 unless box 1 is checked.

This Form is NOT Open
to Public Inspection.

Department of the Treasury
Internal Revenue Service

For calendar plan year 2007 or fiscal plan year beginning
Name of plan

,

and ending

A

C

1

2

Plan sponsor's name as shown on line 2a of Form 5500

B
D

,
Three-digit
plan number έ
Employer Identification Number

Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2
through 3c, and the signature area.
Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)
City or town, state, and ZIP code

3a

Name of plan administrator (if other than sponsor)

3b

Administrator's EIN

3c

Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)
City or town, state, and ZIP code

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGN
HERE

Signature of plan
administrator

έ

Phone number of plan administrator έ

Date έ

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

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Schedule SSA (Form 5500) 2007

Schedule SSA (Form 5500) 2007

Page

2
Official Use Only

4

Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits that:
Code A -- has not previously been reported.
Code B -- has previously been reported under the above plan number but requires revisions to the information previously reported.
Code C -- has previously been reported under another plan number but will be receiving their benefits from the plan listed above instead.
Code D -- has previously been reported under the above plan number but is no longer entitled to those deferred vested benefits.

Use with entry code
"A", "B", "C", or "D"
(a)
Entry
Code

(b)
Social
Security
Number

Use with entry code
"A" or "B"
Enter code for
nature and
form of
benefit

(c)
Name of Participant
(First)

(M.I.)

(d)
Type of
annuity

(Last)

Use with entry code
"A" or "B"
(a)
Entry
Code

Share
indicator

(e)
Payment
frequency

(f)
Defined benefit
plan -- periodic
payment

Use with entry code
"C"

Amount of vested benefit
Defined contribution plan
(g)
Units or
shares

Amount of vested benefit

(h)
Total value
of account

(i)
Previous sponsor's
employer
identification number

(j)
Previous
plan number

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