Schedule SSA Annual Registration Statement Identifying Separated Part

CUMULATIVE CHANGES
Official Use Only

SCHEDULE SSA
(Form 5500)

Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits

For calendar plan year 2008
or fiscal plan year beginning
A

Name of plan

C

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

B

Three-digit
plan number

2

▼

D

and ending

MM / D D / Y Y Y Y

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.

PR

1

This Form is NOT Open
to Public Inspection.

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

MM / D D / Y Y Y Y

2008

O
O
F

Department of the Treasury
Internal Revenue Service

▼

Under Section 6057(a) of the Internal Revenue Code

OMB No. 1210-0110

Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)

State

ZIP code

D

City or town

3b Administrator's EIN

3R

3a Name of plan administrator (if other than sponsor)

3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)

City or town

State

Date

▼

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

2

9

0

8

0

0

0

1

MM / D D / Y Y Y Y

▼

SIGN HERE

▼

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.
Phone number of
Signature of plan administrator
plan administrator

ZIP code

0

Cat. No. 13506T

Schedule SSA (Form 5500) 2008

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Schedule SSA (Form 5500) 2008

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
(First)

(c) Name of participant

(M. I.)

(Last)

Use with entry code "A" or "B"
Amount of vested benefit
Defined contribution plan

Enter code for
nature and
form of benefit
(e)
Payment
frequency

(f) Defined benefit plan -- periodic payment

▲

▲

▲

.

▲

O
O
F

(d)
Type of
annuity

Share
indicator

(g) Units or shares

▲

▲

.

▲

▲

▲

▲

(h) Total value of account

▲

▲

(i) Previous sponsor's employer identification number

(j) Previous plan number

PR

Use with entry code "C"

.

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

(First)

(Last)

(M. I.)

3R

(c) Name of participant

D

(b) Social security number

Use with entry code "A" or "B"

Enter code for
nature and
form of benefit
(d)
Type of
annuity

(e)
Payment
frequency

Amount of vested benefit
Defined contribution plan

Share
indicator

(g) Units or shares

(f) Defined benefit plan -- periodic payment

▲

▲

▲

.
▲

▲

▲

.

▲

▲

▲

▲

(h) Total value of account

▲

▲

(i) Previous sponsor's employer identification number

.

(j) Previous plan number

Use with entry code "C"

2

9

0

8

0

0

0

2

0

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