Form 8955-SSA, Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits

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Page 1 of 7 Instructions for Form 8955-SSA

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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
Reporting Requirement. Neither the elimination of the
Schedule SSA nor the creation of the Form 8955-SSA
affects the requirement under Code section 6057(b) that
plan administrators notify the Secretary of Treasury of
certain changes to the plan and the plan administrator.
These changes are reported on the plan’s Form 5500
annual return/report. Plan administrators should continue to
report those changes on the Form 5500 return/report for the
plan year in which the change occurs as indicated in the
instructions.

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

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What’s New

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• 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
now requires electronic filing for plan years beginning after
December 31, 2008. Schedules under the Form 5500 series
that had filing obligations under the Internal Revenue Code
but not under Title I of ERISA were removed from the Form
5500 series. See the discussion below of Form 8955-SSA,
Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits, that replaced
the Schedule SSA (Form 5500), Annual Return Registration
Statement Identifying Separated Participants With Deferred
Vested Benefits.
• Form 8955-SSA is the designated successor to Schedule
SSA (Form 5500) as the form to be used to satisfy the
reporting requirements of section 6057(a) of the Code for
plan years beginning after December 31, 2008. New Form
8955-SSA is established as a stand-alone reporting form
that is to be filed with the Internal Revenue Service (IRS).
See Where To File. Do not file Form 8955-SSA with the
Form 5500.
• The 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 in 2011.

Telephone Assistance

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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.

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How To Get Forms and Publications
Internet. You can access the IRS website 24 hours a day,
7 days a week at 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.

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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.

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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 of that plan year.
To provide plan administrators with additional time to
complete and file the new Form 8955-SSA, the due date for
filing the form for the 2009 plan year is generally the due
date that applies for filing the Form 8955-SSA for the 2010
plan year. For example, for calendar year plans, any 2009
Form 8955-SSA that is required to be filed under Code
section 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). See the Announcement 2010-xx.

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Photographs of Missing Children

Exception. The special filing due date referred to above for
the 2009 plan year does not apply in cases where the Form
5500 annual return/report filed for the 2009 plan year was
the final return/report of the plan. In those cases, the Form
8955-SSA filed for the 2009 plan year 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.

General Instructions
Purpose of Form

Use Form 8955-SSA to report information about separated
participants with deferred vested benefit rights. Report
participants who:
• separated from service covered by a plan during the plan
year;
• transferred into a plan during the plan year;
• previously were reported under a plan but have been paid
out or are no longer entitled to those deferred vested
benefits; or
• previously were reported under a plan but whose
information is being corrected.

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The 2009 plan year information should not be combined
with the 2010 plan year information and filed on 2010 Form
8955-SSA. The plan year for which you file Form 8955-SSA
must correspond to the year found on the top of the form.

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.

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Page 2 of 7 Instructions for Form 8955-SSA

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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.

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, Short Form Annual Return/Report of Small
Employee Benefit Plan, Form 5500-EZ, Annual Return of
One-Participant (Owners and Their Spouses) Retirement
Plan, and the Form 8955-SSA.

Who Must File

Using Extension of Time To File Federal
Income Tax Return

Plan administrators of plans subject to the vesting standards
of section 203 of ERISA must file Form 8955-SSA.
Government, church, and other plans which are not subject
to the vesting standards of section 203 of ERISA (including
plans that cover only owners and their spouses) may elect
to voluntarily file the Form 8955-SSA. See the instructions
for Part I, line A.
Note. If the 2009 plan year Form 5500 annual return/report
was the final return/report of the plan, the 2009 Form
8955-SSA must be filed to report that previously reported
deferred vested participants are no longer deferred vested
participants. See When To File for special filing date for
2009 plan year.

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 both 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.

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An extension of time granted by using this automatic
extension procedure CANNOT be extended further by filing
a Form 5558. It also cannot be extended beyond more than
91/2 months beyond the close of the plan year.

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When To File

Other Extensions of Time To File
The IRS may from time to time 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 IRS.gov for announcements of special
extensions. If you are relying on a special extension, check
the box on line C and enter the exact language describing
the announcement in the space provided. For example,
indicate “Disaster Relief Extension” or “Combat Zone
Extension.”

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Special Filing Due Date for 2009 plan year. Generally,
Form 8955-SSA must be filed by the last day of the seventh
month following the last day of that plan year. However, to
provide plan administrators additional time to file the new
Form 8955-SSA, the due date for filing the Form 8955-SSA
for the 2009 plan year is generally the due date for filing the
Form 8955-SSA for the 2010 plan year. For example, for
plans on a calendar year, any 2009 Form 8955-SSA
required to be filed under section 6057(a) must be filed with
the IRS by Monday, August 1, 2011. (Because the last day
of the seventh month following the last day of the 2010 plan
year is a Sunday, the filing date is the next business day,
Monday, August 1, 2011.)
Except as provided below, neither the 2009 Form
8955-SSA nor the 2010 Form 8955-SSA is required to be
filed before August 1, 2011. For example, in the case of a
short 2010 plan year, neither the 2009 Form 8955-SSA nor
the 2010 Form 8955-SSA must be filed before August 1,
2011. See Announcement 2010-xx.
Exception. 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 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.

Amended Statement

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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 Part I, line B (“amended registration statement”).
The amended Form 8955-SSA must conform to the
requirements in the How To File section.

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Prior year (before plan year 2009) delinquent Schedule SSA
(Form 5500) filings should be sent to:

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

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.

Extension of Time To File

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Using Form 5558
If filing under an extension of time based on the filing of an
Form 5558, Application for Extension of Time To File
Certain Employee Plan Returns, check the appropriate box
on the Form 8955-SSA, Part I, 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
date (not including any extensions) of the Form 8955-SSA.

Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201-0024

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Short Plan Years

Prior Year Statement

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In general, information on the deferred vested retirement
benefit of a plan participant must be filed no later than on
the Form 8955-SSA filed for the plan year following the plan
year in which the participant separates from service covered
by the plan. However, you can report the separation in the
plan year in which it occurs if you want to report earlier. Do

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When Not To Report a Participant

not report a participant more than once unless you are
revising or updating a Form 8955-SSA or a prior Schedule
SSA (Form 5500). See page 6 of these instructions for Part
III, 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 one-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),
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 participant’s benefit is paid
CAUTION
to the participant, information on the participant’s
remaining benefit 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.

In general, information about to the deferred vested
retirement benefit of a plan participant must be reported on
the Form 8955-SSA filed for the plan year in which the
participant completes the second of two consecutive
one-year breaks in service in service computation periods.
Consecutive one-year breaks in service are defined in the
plan for vesting percentage purposes. The participant may
be reported earlier on the Form 8955-SSA filed for the plan
year in which the participant completed the first one-year
break in service.

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Separation of a Re-Employed
Employee

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

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Employer

Revising Prior Registration Statement
To ensure the SSA’s records are correct, use a 2009 Form
8955-SSA to report revisions to a participant’s information
you reported on a previously filed 2009 Form 8955-SSA or a
Schedule SSA (Form 5500). 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.

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One Form 8955-SSA is generally filed for each plan or entity
described in the 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.
For purposes of 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 if 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” (a controlled group of
corporations under section 414(b), a group of trades or
businesses under common control under section 414(c), or
an affiliated service group under section 414(m)) is generally
one employer for Form 5500 reporting purposes.
For purposes of 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 under one or more collective
bargaining agreements between one or more employee
organizations and more than one employer, and
3. An election under 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 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.

Transfer of a Participant to a New
Plan

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When a separated participant with deferred vested benefits
is transferred from one plan to a new plan,
1. The new plan administrator should complete a Form
8955-SSA using:
• Entry Code C for Part III, line 9, column (a), when the
original plan information is available, or
• Entry Code A for Part III, 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 Part III, line 9,
column (a).

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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
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
section 414(f)(5) or ERISA sections 3(37)(E) and 4001(a)(3).
Participating employers do not file individually for these
plans.

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
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.

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Penalties

The private delivery service can tell you how to get written
proof of the mailing date.

The Internal Revenue Code imposes a penalty for failure to
file a Form 8955-SSA (including failure to include all
required participants). The penalty is $1 for each participant
not reported and for each day multiplied by the number of
days the failure continues. The penalty, up to a maximum of
$5,000, is imposed on the person failing to so file unless it is
shown the failure is due to reasonable cause.
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 the failure is due to
reasonable cause.
The Code requires that each plan administrator required
to file a Form 8955-SSA must, 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. A penalty of $50 is imposed on the person required to
file the statement for each willful failure to furnish the
statement or a willful furnishing of a false statement.

How To File
Follow the 2009 line-by-line instructions to complete the
Form 8955-SSA.
Answer all questions about the plan, unless clearly
instructed not to. 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 to be filed with the DOL EFAST2 system
that replaced EFAST (ERISA Filing Acceptance System)
January 1, 2010. 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.

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Paper Filing

Specific Instructions
Part I

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To reduce the possibility of correspondence and penalties:
• Sign and date the registration statement (Form
8955-SSA).
• Check your information to avoid errors.
• Complete all lines on the form unless otherwise specified.
• All information should be printed in the specific fields
provided on the form.
• Do not mark on or near any barcode.
• 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.
• File the Form 8955-SSA using the address specified in
the instructions under Where To File.
• You may round off cents to whole dollars. If you do round,
you must round all 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.

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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.
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;

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Processing Tips

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Note. If you complete and file the printed form with a
nonstandard page 2, the page 2 must contain the same
information and exact format as the page 2 of the Form
8955-SSA. Filing a nonstandard page 2 may result in
correspondence and in delay in processing the form.

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 in the
following 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 (for instance,
plan administrators of governmental plans and non-electing
church plans, which are not subject to ERISA section 203),
however, 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.
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.

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You can:
• Use [SSA] approved software to complete and submit a
paper Form 8955-SSA.
• Use a personal computer to complete the online fillable
Form 8955-SSA on the IRS website at
www.irs.gov/formspubs/ before printing, signing, and mailing
it to the IRS. A barcode capturing the data you entered on
the form will appear on the completed pages when printed.
A form partially completed online and partially completed
(other than the signature) on printed paper will cause
processing delays and may result in correspondence.
• Order the printed Form 8955-SSA from the IRS by calling
1-800-TAX-FORM (1-800-829-3676). When completing the
form, use as many pages 2 as necessary and number them
in sequential order.

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• 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 for line 5 about changes in sponsorship).

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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 EIN. Plan
administrators 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
recently filed Schedule SSA (Form 5500) or Form
8955-SSA.

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Line 2b. Enter the employer’s nine-digit 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 IRS.gov.
• Call 1-800-829-4933 to receive your EIN by telephone.
• Select the Online EIN Application link at 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 for line 5 about
changes 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:
• 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.

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 recently filed Schedule SSA (Form
5500) or Form 8955-SSA for this plan, enter the plan
sponsor’s name, EIN, and the plan number as they
appeared on the most recently 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 one-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
completed the first one-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.

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Page 6 of 7 Instructions for Form 8955-SSA

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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.

in any deferred retirement benefit but there is a significant
likelihood that the participant is vested in such a benefit. See
Regulations section 1.6057-1(b)(3).
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
one-year break in service under the plan).

Part III
Line 9, column (a). Enter the appropriate code from the
following list:
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 a 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).

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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Line 9, column (b). Enter the exact 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 for
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 regarding
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 as to the
participant’s covered service (or other relevant service) or
2. The plan administrator is unable to determine from the
records of the participant’s service if the participant is vested

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.

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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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Page 7 of 7 Instructions for Form 8955-SSA

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Paperwork Reduction Act Notice
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 and 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 49 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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