Form 8955-SSA Annual Registration Statement Identifying Separated Part

Form

8955-SSA

Department of the Treasury
Internal Revenue Service

PART I

Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits
Under Section 6057 of the Internal Revenue Code

OMB No.

2009

This Form is NOT Open
to Public Inspection

Annual Statement Identification Information

For the plan year beginning
, and ending
← Check here if plan is a government, church, or other plan that elects to voluntarily file Form 8955-SSA. (See instructions.)
A
← Check here if this is an amended registration statement.
B
Check the appropriate box if filing under:

C

PART II

Form 5558
Automatic extension
Special extension (enter description)

Basic Plan Information - enter all requested information

1a Name of plan

1b Three-digit Plan Number (PN)

Plan Sponsor Information
2a Plan sponsor’s name

2b Employer Identification Number (EIN)

2c Trade name (if different from plan sponsor name)

2d Plan sponsor's phone number

2e In care of name
2f Mailing address (room, apt., suite no. and street, or P.O. Box)

2g City

2h State

2i ZIP code

2j Foreign province (or state)

2k Country

2l Foreign postal code

Plan Administrator Information
3a Plan administrator’s name (if other than plan sponsor)

3b Employer Identification Number (EIN)

3c In care of name

3d Plan administrator’s phone number

3e Mailing address (room, apt., suite no. and street, or P.O. Box)

3f City

3g State

3h ZIP code

3i Foreign province (or state)

3j Country

3k Foreign postal code

4 If the name or EIN of the plan administrator has changed since the last return filed for this plan, enter the name and EIN from the last filed return:
Plan administrator’s name

EIN

5 If the name or EIN of the plan sponsor has changed since the last return filed for this plan, enter the name, EIN, and plan number from that return:
Plan sponsor’s name
6

7
8

EIN

Three-digit Plan Number

a. How many participants who separated with a deferred vested benefit are required to be reported on this Form 8955-SSA

6a

b. How many participants who separated with a deferred vested benefit are voluntarily reported on this Form 8955-SSA
6b
in the same year as the separation occurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What is the number of total participants reported on this Form 8955-SSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Did the plan administrator provide an individual statement to each participant required to receive a statement . . . . . . . . . . . .
Yes
No
Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct, and complete.
Incomplete or missing information may cause a delay in processing and result in correspondence.
Signature of plan sponsor
Date signed
Signature of plan administrator
Date signed

Sign
Here

©

For Paperwork Reduction Act Notice, see the separate instructions

Cat. No. 52729U

Form 8955-SSA (2009)

Form 8955-SSA (2009)

Page 2

Name of plan
PART III

Plan Number

EIN

Participant Information - enter all requested information

9 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 whose previously reported information requires revisions.
Code C — has previously been reported under another plan, but who will be receiving benefits from the plan listed above instead.
Code D — has previously been reported under the above plan number, but whose benefits have been paid out or who 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 (See instructions.)
First Name

M.I.

Last Name

U

(d) Type of
Annuity

(e) Payment
Frequency

Amount of vested benefit
(f) Defined
benefit plan
periodic payment

Defined Contribution Plan
(g) Total value of account

Use with entry code "C" only
(h)
Previous
Sponsor’s
EIN

(i)
Previous
Plan
Number

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2009

Department of the Treasury
Internal Revenue Service

Instructions for Form
8955-SSA

Annual Registration Statement Identifying Separated Participants With Deferred
Vested Benefits

What’s New

!

Filers should not use a prior year Schedule SSA
(Form 5500), for 2008 and earlier filings, or to report
2009 plan year information.

CAUTION

Telephone Assistance
If you have questions and need assistance completing this
form, call the IRS Help Line at 1-877-829-5500 and follow
the directions as prompted. This toll-free telephone service
is available Monday through Friday.

D

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AF

• In 2007, the Department of Labor (DOL) published a final
rule requiring electronic filing of the Form 5500, Annual
Return/Report of Employee Benefit Plan, series. The DOL
electronic filing mandate is effective for plan years beginning
on or after January 1, 2009 and does not apply to the
reporting requirements for deferred vested participants
under section 6057(a). In order to implement the DOL’s
mandate for electronic filing of the Form 5500 annual return/
report, some schedules of the Form 5500 series such as
Schedule SSA (Form 5500) required to satisfy filing
obligations imposed by the Internal Revenue Code, but not
required under ERISA, were removed as schedules to the
Form 5500 series.
• Form 8955-SSA, Annual Registration Statement
Identifying Separated Participants With Deferred Vested
Benefits, is designated as a replacement to Schedule SSA
(Form 5500) as the form to be used to satisfy the reporting
requirements of § 6057(a) of the Internal Revenue Code for
plan years beginning on or after January 1, 2009. New Form
8955-SSA is established as a stand-alone reporting form
that is to be filed with the Internal Revenue Service. See
Where To File.Do not file Form 8955-SSA with the Form
5500.
• The Internal Revenue Service (IRS) is in the process of
creating an electronic filing system for the Form 8955-SSA
and anticipates that the electronic filing system will be
available for the 2010 plan year.

than the later of the last day of the seventh month following
the last day of the plan year or March 31, 2011.
Notice Requirement Regulations section 1.6057 – 2
requires notification of certain changes relating to the plan
and plan administrator be reported on the Form 5500 series
for plan year in which the change occurs. Neither the
elimination of the Schedule SSA nor the creation of the
Form 8955 – SSA impact this requirement. Therefore, a plan
administrator should continue to report changes in plan
status on Form 5500 series for the plan year in which the
change occurs.

T

Code section references are to the Internal Revenue Code, unless
otherwise noted. ERISA refers to the Employee Retirement Income
Security Act of 1974.

Special Filing Due Dates for 2009 Plan Year In general,
as with Schedule SSA (Form 5500), if a Form 8955 – SSA
must be filed for a plan year, it must be filed by the last day
of the seventh month following the last day that plan year.
However, in order to provide plan administrators with
additional time to complete and filed the new Form
8955 – SSA, the due date for filing the Form 8955 – SSA for
the 2009 plan year is generally the due date that applies for
filing the Form 8955 – SSA for the 2010 plan year. Thus, for
example, for plans on a calendar year, any 2009 Form
8955-SSA that is required to be filed under § 6057(a) must
be filed with the IRS by Monday, August 1, 2011 (since July
31, 2011, the last day of the seventh month following the
last day of 2010 plan year, is a Sunday).
The 2009 plan year information cannot be combined with
the 2010 plan year information and filed on 2010 Form
8955 – SSA. You must use different form for each year.
Exception: The change in due date for the 2009 Form
8955 – SSA does not apply, however, in those cases where
the Form 5500 annual return/report filed for 2009 plan year
was the final return/report of the plan. In that case, the Form
8955 – SSA filed for the 2009 plan year must be filed no later

How To Get Forms and Publications

Internet. You can access the IRS website 24 hours a day,
7 days a week at www.irs.gov to:
• Download forms, instructions, and publications;
• Order IRS products online;
• Research your tax questions online;
• Search publications on-line by topic or keyword; and
• Sign up to receive local and national tax news by email.
By phone and in person. You can order forms and IRS
publications by calling 1-800-TAX-FORM (1-800-829-3676).
You can also get most forms and publications at your local
IRS office.

Photographs of Missing Children
The Internal Revenue Service is a proud partner with the
National Center for Missing and Exploited Children.
Photographs of missing children selected by the Center may
appear in instructions on pages that would otherwise be
blank. You can help bring these children home by looking at
the photographs and calling 1-800-THE-Lost
(1-800-843-5678) if you recognize a child.

General Instructions
Purpose of Form
Use Form 8955-SSA, Annual Registration Statement
Identifying Separated Participants With Deferred Vested
Benefits, to report information concerning separated
participants with deferred vested benefit rights. Report
participants who:
• separated from service covered by the plan during the
plan year; or

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• transferred into this plan during the plan year; or
• previously were reported under this plan but have been

date (not including any extensions) of the Form 8955-SSA.
See the instructions for Form 5558. You must file the Form
5558 with the Department of the Treasury, Internal Revenue
Service Center, Ogden, UT 84201-0027. Approved copies of
the Form 5558 will not be returned to the filer. A single Form
5558 may be used for extensions of time for the Form 5500,
Form 5500-SF, Form 5500-EZ, and the Form 8955-SSA.

paid out or are no longer entitled to those deferred vested
benefits; or
• previously were reported under this plan but whose
information is being corrected.
The information reported on Forms 8955-SSA is given to
the Social Security Administration (SSA). The SSA provides
the reported information to separated participants when they
file for social security benefits.
Note. Report required information regarding separated
participants only on page 2 of Form 8955-SSA. If additional
space is needed for separated participants, use additional
pages 2 only; do not add another page 1 of Form 8955-SSA.

Using Extension of Time To File Federal
Income Tax Return
An automatic extension of time to file Form 8955-SSA until
the due date of the federal income tax return of the
employer will be granted if all of the following conditions are
met.
1. The plan year and the employer’s tax year are the
same.
2. The employer has been granted an extension of time
to file its federal income tax return to a date later than the
normal due date for filing the Form 8955-SSA.
3. A copy of the application for extension of time to file
the federal income tax return is attached to the Form
8955-SSA. (Check the appropriate box on Form 8955-SSA,
line C.)

Who Must File

Other Extensions of Time To File

The IRS may announce special extensions of time under
certain circumstances, such as extensions for
presidentially-declared disasters or for service in, or in
support of, the Armed forces of the United States in a
combat zone. See www.irs.gov for announcements
regarding such special extensions. If you are relying on one
of these announced special extensions, check the box on
line C and enter the exact language describing the citation in
the announcement for the extension in the space provided.
For example, indicate “Disaster Relief Extension” or
“Combat Zone Extension.”

AF

When To File

An extension of time granted by using this automatic
extension procedure CANNOT be extended further by filing
a Form 5558, nor can it be extended beyond a total of 91/2
months beyond the close of the plan year.

T

Except as provided below, plan administrators of plans
subject to the vesting standards of section 203 of ERISA
must file Form 8955-SSA. Plans that cover only owners and
their spouses do not have to file this form. However,
government, church, and other plans which are not subject
to the vesting standards of section 203 of ERISA may elect
to voluntarily file the Form 8955-SSA. See the instructions
for line A.
Note. If Form 5500 annual return/report filed for the 2009
plan year was the final return/report of the plan, the 2009
Form 8955 – SSA must be filed. See When To File for
special filing due date.

R

Form 8955 – SSA must be filed by the last day of the
seventh month following the last day that plan year.
However, in order to provide plan administrators with
additional time to complete and filed the new Form
8955 – SSA, the due date for filing the Form 8955 – SSA for
the 2009 plan year is generally the due date that applies for
filing the Form 8955 – SSA for the 2010 plan year. Thus, for
example, for plans on a calendar year, any 2009 Form
8955-SSA that is required to be filed under § 6057(a) must
be filed with the IRS by Monday, August 1, 2011 (since July
31, 2011, the last day of the seventh month following the
last day of 2010 plan year, is a Sunday).
If Form 5500 annual return/report filed for 2009 plan year
was the final return/report of the plan, the 2009 Form
8955 – SSA must be filed no later than the later of the last
day of the seventh month following the last day of the plan
year or March 31, 2011.
Plans with a foreign address should wait to file their 2009
participant information for Form 8955-SSA until they can
electronically file their 2010 participant information.

Amended Statement

D

File a Form 8955-SSA to correct errors and/or omissions in
a previously filed statement for the 2009 plan year. Check
the box for line B (“amended registration statement”). The
amended Form 8955-SSA must conform to the
requirements in the How To File section.

Prior Year Statement
If a plan administrator needs to report a separated
participant (previously unreported) from a prior plan year,
the plan administrator would use the current version of the
Form 8955-SSA and include the year beginning and ending
date for the year in question. Filers completing a statement
for a prior plan year are not required to complete line 8 for
plan years prior to 2009.

Short Plan Years
For a plan year of less than 12 months (short plan year), fill
in the short plan year beginning and ending dates on the line
provided at the top of the form. For purposes of this form,
the short plan year ends on the date of the change in
accounting period or upon the complete distribution of
assets of the plan.

When To Report a Separated
Participant

Extension of Time To File
Using Form 5558

In general, for a plan to which only one employer
contributes, a participant must be reported on Form
8955-SSA if:
1. The participant separates from service covered by the
plan in a plan year, and
2. The participant is entitled to a deferred vested benefit
under the plan.

If filing under an extension of time based on the filing of an
IRS Form 5558, Application for Extension of Time To File
Certain Employee Plan Returns, check the appropriate box
on the Form 8955-SSA, line C. A one-time extension of time
to file the Form 8955-SSA (up to 21/2 months) may be
obtained by filing Form 5558 on or before the normal due

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In general, the separated participant must be reported no
later than on the Form 8955-SSA filed for the plan year
following the plan year in which separation occurred.
However, you can report the separation in the plan year in
which it occurs if you want to report earlier. Do not report a
participant more than once unless you wish to revise or
update a prior Form 8955-SSA (see instructions for line 9,
under codes B, C, or D).
In general, for a plan to which more than one
employer contributes, a participant must be reported on
Form 8955-SSA if:
1. The participant incurs two successive 1-year breaks in
service (as defined in the plan for vesting purposes), and
2. The participant is (or may be) entitled to a deferred
vested benefit under the plan.

A participant is not required to be reported on Form
8955-SSA if, before the date the Form 8955-SSA is required
to be filed (including any extension of time for filing), the
participant:
1. Is paid some or all of the deferred vested retirement
benefit (see the Caution below), or
2. Returns to service covered by the plan and/or accrues
additional retirement benefits under the plan, or
3. Forfeits all the deferred vested retirement benefit.
If payment of the deferred vested retirement benefit
ceases before ALL of the benefit to which the
CAUTION
participant is entitled is paid to the participant,
information relating to the deferred vested retirement benefit
to which the participant remains entitled shall be filed on the
Form 8955-SSA filed for the year following the last plan year
within which a portion of the benefit is paid to the participant.

!

Separation of a Re-Employed
Employee

If the deferred vested benefit of a separated employee is
different from that benefit previously reported, you may use
code B (see line 9 below) to report that employee’s total
vested benefit.

AF

Employer

When Not To Report a Participant

T

The participant must be reported no later than on the
Form 8955-SSA filed for the plan year in which the
participant completed the second of the two consecutive
1-year breaks in service. The participant may be reported
earlier (that is, on the Form 8955-SSA filed for the plan year
in which he or she separated from service or completed the
first 1-year break in service).
Note. Plan administrators of non-termination plans may,
but are not required to, file Form 8955-SSA for the 2009
plan year. See What’s New. Plan administrators who do not
file a 2009 Form 8955-SSA must include the 2009 plan year
information on their 2010 Form 8955-SSA.

bargained and collectively funded, but if covered by Pension
Benefit Guaranty Corporation (PBGC) termination
insurance, must have properly elected before September
27, 1981, not to be treated as a multiemployer plan under
Code section 414(f)(5) or ERISA sections 3(37)(E) and
4001(a)(3). Participating employers do not file individually
for these plans.

One Form 8955-SSA is generally filed for each plan or entity
described in these instructions. The terms “single-employer
plan”, “controlled group”, “multiemployer plan”, and
“mulitple-employer plan” are defined for purposes of this
Form 8955-SSA as they are defined for purposes of the
Form 5500, Annual Return/Report of Employee Benefit
Plan.
For purposes of this Form 8955-SSA, a “single-employer
plan” is a plan maintained by one employer or one employee
organization.
A separate Form 8955-SSA must be filed by each
employer participating in a plan or program of benefits in
which the funds attributable to each employer are available
to pay benefits only for that employer’s employees, even if
the plan is maintained by a controlled group. A “controlled
group ” is generally considered one employer for Form 5500
reporting purposes. A “controlled group” is a controlled
group of corporations under Code section 414(b), a group of
trades or businesses under common control under Code
section 414(c), or an affiliated service group under Code
section 414(m).
For purposes of this Form 8955-SSA, “multiemployer
plans” and “multiple-employer plans” are treated as plans to
which more than one employer contributes. A plan is a
“multiemployer plan” if:
1. More than one employer is required to contribute,
2. The plan is maintained pursuant to one or more
collective bargaining agreements between one or more
employee organizations and more than one employer, and
3. An election under Code section 414(f)(5) and ERISA
section 3(37)(E) has not been made. A plan that made a
proper election under ERISA section 3(37)(G) and Code
section 414(f)(6) on or before August 17, 2007, is also a
multiemployer plan. Participating employers do not file
individually for these plans. See 29 CFR 2510.3-37.

Revising Prior Registration Statement

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Use a 2009 Form 8955-SSA to report revisions to
information for a participant you reported on a previously
filed 2009 Form 8955-SSA or a Schedule SSA (Form 5500).
This will ensure that the SSA’s records are correct. This is
important since SSA provides Form 8955-SSA information
that it has on file to participants when they file for social
security benefits. If this information is not up-to-date, the
participant may contact the plan administrator to resolve the
difference.

Transfer of a Participant to a New
Plan
When a separated participant with deferred vested benefits
is transferred from the plan he or she was originally reported
under to a new plan,
1. The new plan administrator should complete a Form
8955-SSA using:
• Entry Code C for line 9, column (a), when the original
plan information is available, or
• Entry Code A for line 9, column (a), when the original
plan information is not available.
2. The original plan administrator should complete a
Form 8955-SSA using Entry Code D for line 9, column (a).

Where To File
Send the completed Form 8955-SSA to:
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201-0027
Private delivery services (PDSs). In addition to the United
States mail, you can use the private delivery services

A “multiple-employer plan” is a plan maintained by more
than one employer and is not one of the plans already
described. A multiple-employer plan can be collectively

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• You may show the money items on the form as
whole-dollar amounts. To do so, drop any amount less than
50 cents and increase any amount from 50 to 99 cents to
the next higher dollar.

designated by the IRS to meet the “timely mailing as timely
filing/paying” rule for [tax returns and payments]. These
delivery services include only the following.
• DHL Express (DHL): DHL Same Day Service.
• Federal Express (FedEx): FedEx Priority Overnight,
FedEx Standard Overnight, FedEx 2Day, FedEx
International Priority, FedEx International First.
• United Parcel Service (UPS): UPS Next Day Air, UPS
Next Day Air Saver, UPS 2nd Day Air, UPS 2nd Day Air AM,
UPS Worldwide Express Plus, and UPS Worldwide Express.
The private delivery service can tell you how to get written
proof of the mailing date.

Penalties
In the case of a failure to file a Form 8955-SSA which
includes all participants required to be included, the Internal
Revenue Code imposes a penalty of $1 for each participant
with respect to whom there is a failure to file, multiplied by
the number of days during which such failure continues. The
penalty, up to a maximum of $5,000, is imposed on the
person failing to so file unless it is shown such failure is due
to reasonable cause.

How To File
The statement must be completed in accordance with the
line-by-line instructions for the 2009 Form 8955-SSA.
Answer all questions with respect to the plan, unless
otherwise clearly stated in the instructions, or on the form
itself. Responses usually apply to the form year entered or
printed at the top of the first page of the form.
The Form 8955-SSA and any attachments that are
filed under ERISA are NOT open to public
CAUTION
inspection. DO NOT attach a Form 8955-SSA or a
previous year’s Schedule SSA (Form 5500) to a Form 5500
or Form 5500-SF, Short Form Annual Return/Report of
Small Employee Benefit Plan, to be filed with the DOL
EFAST2 system. The Form 8955-SSA must be filed with the
IRS and cannot be attached to a Form 5500, a Form
5500-EZ, or a Form 5500-SF. Because of privacy concerns,
the inclusion of a social security number on the Form 5500,
Form 5500-EZ, Form 5500-SF, or on a schedule or
attachment that is filed with the DOL using EFAST2 may
result in the return of the filing.

In the case of a failure to file a notification of a change in
the status of the plan (such as a change in the plan name or
a termination of the plan), or a change in the name or
address of the plan administrator, the Code imposes a
penalty of $1 for each day during which such failure occurs.
The penalty, up to a maximum of $1,000, is imposed on the
person failing to so file unless it is shown such failure is due
to reasonable cause.

!

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Paper Filing

The Code requires that each plan administrator required
to file a Form 8955-SSA shall, before the expiration of the
time prescribed for the filing of the Form 8955-SSA, also
furnish to each affected participant an individual statement
setting forth the information required to be contained in the
form. In the case of a willful failure to furnish the statement,
or a willful furnishing of a false statement, a penalty of $50 is
imposed on the person so acting for each such failure.

Specific Instructions
Part I

You can order paper printed 2009 Forms 8955-SSA for
completion by hand by calling 1-800-829-3676 or visiting the
IRS website at www.irs.gov/formspubs/.
Using a personal computer and the IRS website at
www.irs.gov/formspubs/, you can complete a fillable Form
8955-SSA online to print and sign before mailing. Forms
partially filled in online then printed and partially completed
by hand (other than the signature) may not be processed.
You can also choose to use approved software to
complete and submit a paper Form 8955-SSA .

D

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Enter the calendar or fiscal year beginning and ending dates
of the plan year for which you are reporting information.
Express the dates in numerical month, day, and year order
(“MMDDYYYY”).
Line A. Check this box if you are voluntarily electing to file
this form. The plan administrators of plans subject to the
vesting standards of section 203 of ERISA must file this
Form 8955-SSA.
Note. The plan administrators of other plans, however,
such as the plan administrators of governmental plans and
non-electing church plans, which are not subject to ERISA
section 203, are not required to file this form but may elect
to do so. If such a plan administrator so elects, the plan
administrator is encouraged to provide as much information
as possible, but no specific requirements are imposed.

Processing Tips

To reduce the possibility of correspondence and penalties:
• Sign and date the registration statement.
• Check your information to avoid errors.
• Complete all lines on the form unless otherwise specified.
Incomplete forms will be returned. [will or may — Will SSA
return the incomplete forms to the filer and have the filer
return missing information to SSA?]
• All information should be printed in the specific fields
provided on the form.
• Do not mark on or near any bar code.
• A form that is partially completed online or using
generated, approved software, and then completed by pen
or typewriter will not be processed.
• Paper should be clean without glue or other sticky
substances.
• Do not staple the form pages. Use binder clips or other
fasteners that do not perforate the paper.
• Do not submit extraneous material or information, such as
arrows used to indicate where to sign, notes between
preparers of the report, or notations on the form.
• All Forms 8955-SSA must be filed using the address
specified in the instructions. (See Where To File.)

Line B. Check this box if this Form 8955-SSA amends a
previously filed Schedule SSA (Form 5500) or Form
8955-SSA.
Line C. Check the appropriate box if an extension of time
has been filed using Form 5558, or if an automatic or special
extension has been granted. If a special extension has been
granted, enter the description of the special extension
exactly as it is listed in the announcement. See Other
Extensions of Time To File for additional information
regarding special extensions.

PART II
Please verify that the employer identification number (EIN)
and plan number (PN) being used on this Form 8955-SSA
are correct for this plan.
Line 1a. Enter the formal name of the plan or enough
information to identify the plan. Abbreviate if necessary.

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T

• The person or group of persons specified as the
administrator by the instrument under which the plan is
operated;
• The plan sponsor/employer if an administrator is not so
designated; or
• Any other person prescribed by regulations if an
administrator is not designated and a plan sponsor cannot
be identified.
Note. Employees of the plan sponsor who perform
administrative functions for the plan are generally not the
plan administrator unless specifically designated in the plan
document. If an employee of the plan sponsor is designated
as the plan administrator, that employee must obtain an
EIN.
Line 3b. Enter the plan administrator’s nine-digit employer
identification number (EIN). Plan administrator who do not
have an EIN, must apply for one as described in the
instructions for line 2b.
Line 3c. If you want a third party to receive mail for the
plan sponsor, enter “C/O” followed by the third party’s name
and complete the applicable mailing address in lines 3e
through 3k.
Line 3e. Enter the plan administrator’s street address. A
post office box may be entered if the Post Office does not
deliver mail to the sponsor’s street address.
Line 3f. Enter the name of the city.
Line 3g. Enter the two-character abbreviation for the U.S.
state or possession.
Line 3i. Enter the foreign province or state, if applicable.
Line 3j. Enter the foreign country, if applicable.
Line 3k. Enter the foreign routing code, if applicable. Leave
the U.S. state and zip code blank if completing line 3j or line
3k.
Line 4. If the plan administrator’s name and/or EIN have
changed since the most recent Schedule SSA (Form 5500)
or Form 8955-SSA was filed for this plan, enter the plan
sponsor’s name and EIN as they appeared on the most
recent filed Schedule SSA (Form 5500) or Form 8955-SSA.

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Line 1b. Enter the three-digit plan number that the
employer or plan administrator assigned to the plan uses for
filing the Form 5500 series.
Line 2a. Enter the name of the plan sponsor. The term
“plan sponsor” means:
• the employer, for a plan that a single-employer
established or maintains;
• the employee organization in the case of a plan of an
employee organization; or
• the association, committee, joint board of trustees, or,
other similar group or representatives of the parties who
establish or maintain the plan, if the plan is established or
maintained jointly by one or more employers and one or
more employee organizations, or by two or more employers.
Note. In the case of a multiple employer plan, if an
association or similar entity is not the sponsor, enter the
name of a participating employer as sponsor. A plan of a
controlled group of corporations should enter the name of
one of the sponsoring members. In either case, the same
name must be used in all subsequent filings of the Form
8955-SSA for the multiple-employer plan or controlled group
(see instructions to line 5 concerning change in
sponsorship).
Line 2b. Enter the employer’s nine-digit employer
identification number (EIN). Do not use a social security
number (SSN). Employers without an EIN must apply for
one as soon as possible.
EINs are issued by the IRS. To apply for an EIN:
• Mail or fax Form SS-4, Application for Employer
Identification Number, obtained by calling 1-800-TAX-FORM
(1-800-829-3676) or at the IRS website at www.irs.gov.
• Call 1-800-829-4933 to receive your EIN by telephone.
• Select the Online EIN Application link at www.irs.gov. The
EIN is issued immediately once the application information
is validated. (The online application process is not yet
available for corporations with addresses in foreign
countries or Puerto Rico.)
A multiple-employer plan or plan of a controlled group of
corporations should use the EIN of the sponsor identified in
line 2a. The EIN must be used in all subsequent filings of
the Form 8955-SSA. (See instructions to line 5 concerning
change in EIN.)
If the plan sponsor is a group of individuals, get a single
EIN for the group (providing the group name).
Line 2c. Enter the plan sponsor’s trade name if that trade
name is different from the plan sponsor’s name entered on
line 2a.
Line 2e. If you want a third party to receive mail for the
plan, enter “C/O” followed by the third party’s name and
complete the applicable mailing address in lines 2f through
2l.
Line 2f. Enter the sponsor’s street address. A post office
box may be entered if the Post Office does not deliver mail
to the sponsor’s street address.
Line 2g. Enter the name of the city.
Line 2h. Enter the two-character abbreviation for the U.S.
state or possession.
Line 2j. Enter the foreign province or state, if applicable.
Line 2k. Enter the foreign country, if applicable.
Line 2l. Enter the foreign routing code, if applicable. Leave
the U.S. state and zip code blank if completing line 2k or line
2l.
Line 3a. Enter the plan administrator’s name. Enter “Same”
if the plan administrator identified on line 3a is the same as
the plan sponsor identified on line 2a and leave the
remainder of line 3a blank, and lines 3b through 3c blank.
Plan administrator for this purpose means:

Failure to indicate on line 4 that a plan administrator
was previously identified by a different name or EIN
CAUTION
could result in correspondence from the IRS.
Line 5. If the plan sponsor’s name and/or EIN have
changed since the most recent Schedule SSA (Form 5500)
or Form 8955-SSA was filed for this plan, enter the plan
sponsor’s name, EIN, and the plan number as they
appeared on the most recent filed Schedule SSA (Form
5500) or Form 8955-SSA.

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Failure to indicate on line 5 that a plan sponsor was
previously identified by a different name or EIN could
CAUTION
result in correspondence from the IRS.
Line 6a. For a plan to which only one employer contributes,
provide the total number of participants entitled to a deferred
vested benefit who separated from service in the 2008 plan
year and who were not reported on the 2008 Schedule SSA
(Form 5500). For a plan to which more than one employer
contributes, provide the total number of participants entitled
to a deferred vested benefit who completed the second of
two consecutive 1-year breaks in service in the 2009 plan
year and who were not reported on the 2008 Schedule SSA
(Form 5500).
Line 6b. For a plan to which only one employer
contributes, provide the total number of participants entitled
to a deferred vested benefit who separated from service in
the 2009 plan year and who are reported on this form. for a
plan to which more than one employer contributes, provide
the total number of participants entitled to a deferred vested
benefit who separated from service in 2009 or who

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completed the first 1-year break in service in the 2009 plan
year, and who are reported on this form. See When To
Report a Separated Participant.
Line 7. The sum of lines 6a and 6b should equal the
number on line 7.
Line 8. Check the appropriate box as to whether the plan
administrator provided the individual statement to each
participant required to receive one. See Penalties.
Signature. This form must be signed and dated by the plan
sponsor and by the plan administrator. If more than one
page 2 is filed for one plan, only the initial page one should
be signed.
Line 9, column (a). Enter the appropriate code from the
following list:

Line 9, column (d). From the following list, select the code
that describes the type of annuity that will be provided for
the participant. enter the code that describes the type of
annuity that normally accrues under the plan at the time of
the participant’s separation from service covered by the plan
(or for a plan to which more than one employer contributes
at the time the participant incurs the second consecutive
1-year break in service under the plan).
Type of Annuity Code
A A single sum
B Annuity payable over fixed number of years
C Life annuity
D Life annuity with period certain
E Cash refund life annuity
F Modified cash refund life annuity
G Joint and last survivor life annuity
M Other

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Line 9, column (e). From the following list, select the code
that describes the benefit payment frequency during a
12-month period.
Type of Payment Code
A Lump sum
B Annually
C Semiannually
D Quarterly
E Monthly
M Other

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Code A Use this code for a participant not previously reported.
Also complete columns (b) through (g).
Code B Use this code for a participant previously reported under
the plan number shown on this form to modify some of the
previously reported information. Enter all the current
information for columns (b) through (g). You do not need
to report a change in the value of a participant’s account
since that is likely to change. However, you may report
such a change if you want.
Code C Use this code for a participant previously reported under
the plan of a different plan sponsor and who will now be
receiving his/her future benefit from the plan reported on
this form. Also complete columns (b), (c), (h), and (i).
Code D Use this code for a participant previously reported under
the plan number shown on this form who is no longer
entitled to those deferred vested benefits. This includes a
participant who has begun receiving benefits, has
received a lump-sum payout, or has been transferred to
another plan. (For example, in the case of a plan
termination.) Also complete columns (b) and (c).

2. the plan administrator is unable to determine from the
records of the participant’s service as to whether or not the
participant is vested in any deferred retirement benefit but
there is a significant likelihood that the participant is vested
in such a benefit. See 26 CFR 1.6057-1(b)(3).

Line 9, column (b). Enter the exact social security number
(SSN) of each participant listed. If the participant is a foreign
national employed outside the United States who does not
have an SSN, enter the word “FOREIGN.”
Line 9, column (c). Enter each participant’s name exactly
as it appears on the participant’s social security card. Do not
enter periods; however, initials, if on the social security card,
are permitted.
After the last name column, there is a check mark
column. Check the box for each participant whose
information is based on incomplete records. Information with
respect to a participant may be based on incomplete records
where more than one employer contributes to the plan and
the records at the end of the plan year are incomplete with
respect to the participant’s service. Check the box next to a
participant’s name if:
1. the amount of the participant’s vested benefit is based
on records which are incomplete with respect to the
participant’s covered service (or other relevant service) or

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Line 9, column (f). For a defined benefit plan, enter the
amount of the periodic payment that a participant is entitled
to receive.

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For a multiemployer plan, if the amount of the periodic
payment cannot be accurately determined because the plan
administrator does not maintain complete records of
covered service, enter an estimated amount.
Line 9, column (g). For defined contribution plans, enter
the value of the participant’s account at the time of
separation.
Line 9, columns (h) and (i). Show the EIN and plan
number of the plan under which the participant was
previously reported.

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Paperwork Reduction Act Notice

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We ask for the information on this form to carry out the law as specified in Code section 6057. You are required to give us
the information. We need it to determine whether the plan is operating according to the law.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless
the form displays a valid OMB control number. Books and records relating to a form or its instructions must be retained as
long as their contents may become material in the administration of the Internal Revenue Code. Generally, tax returns and
return information are confidential, as required by Code section 6103.
However, section 6103 allows or requires the Internal Revenue Service to disclose or give the information shown on your
tax return to others as described in the Code. For example, we may disclose your tax information to the Department of
Justice to enforce the tax laws, both civil an criminal, and to cities, states, the District of Columbia, U.S. commonwealths or
possessions, and certain foreign governments, to carry out their tax laws. We may also disclose this information to other
countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal law, or to federal law
enforcement and intelligence agencies to combat terrorism.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average
time is [XX] minutes.
If you have comments concerning the accuracy of the time estimate or suggestions for making this form simpler, we would
be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to this address.
Instead, see Where To File on page 3.

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