i8955-ssa--2021-00-00

2021

Department of the Treasury
Internal Revenue Service

Instructions for Form
8955-SSA
Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits
Section references are to the Internal Revenue Code, unless
otherwise noted. ERISA refers to the Employee Retirement
Income Security Act of 1974.

A Form 8955-SSA need not be filed for a year if no
information is required to be provided for that year by these
instructions.

Future developments. For the latest information about
developments related to Form 8955-SSA and its instructions,
such as legislation enacted after they were published, go to
IRS.gov/Form8955SSA.

Form 8955-SSA may be filed electronically through the
FIRE system or on paper. The IRS and the SSA encourage
all filers to file Form 8955-SSA electronically. Filing
electronically saves time and effort and helps ensure
accuracy. Certain filers, however, are required to file the
2021 Form 8955-SSA electronically. For more information,
see How To File.

Purpose of Form

Form 8955-SSA, the designated successor to Schedule SSA
(Form 5500), is used to satisfy the reporting requirements of
section 6057(a). Form 8955-SSA is a stand-alone reporting
form filed with the IRS. See Where To File. DO NOT file
Form 8955-SSA with Form 5500, Annual Return/Report of
Employee Benefit Plan, or Form 5500-SF, Short Form
Annual Return/Report of Small Employee Benefit Plan.
Use Form 8955-SSA to report information relating to each
participant who separated from service covered by the plan
and is entitled to a deferred vested benefit under the plan but
is not paid this retirement benefit. The plan administrator of
each plan subject to the vesting requirements must file Form
8955-SSA for participants who have a deferred vested
benefit under the plan and:
• Separated from service covered by the plan, but vested
retirement benefits are not paid and were not previously
reported (using Entry Code A in Part III, line 9, column (a));
• Were previously reported under the plan but whose
information is being corrected (using Entry Code B in Part III,
line 9, column (a));
• Were previously reported as deferred vested participants
on another plan's filing if their benefits were transferred (other
than in a rollover) to the plan of a new employer during the
covered period (using Entry Code C in Part III, line 9, column
(a); or
• Were previously reported under the plan but have been
paid out or are no longer entitled to those deferred vested
benefits (using Entry Code D in Part III, line 9, column (a)).
For more information on required participant information,
see the instructions for Part III.
The information reported on Forms 8955-SSA is generally
given to the Social Security Administration (SSA). The SSA
provides the reported information to separated participants
when they file for social security benefits.
Note. The SSA no longer processes nonstandard pages 2.
Report information about 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, spreadsheets, or
other nonstandard formats.

Jan 04, 2022

Reporting requirement. Under section 6057(b), plan
administrators must notify the Secretary of the Treasury of
certain changes to the plan and the plan administrator. These
changes are reported on the plan’s Form 5500 return/report.
Plan administrators should report these changes on the Form
5500 return/report for the plan year in which the change
occurs as indicated in the Form 5500 instructions.

Telephone Assistance

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

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 online by topic or keyword; and
• Sign up to receive local and national tax news by email.
You can find forms, instructions, and publications by
visiting the IRS website at IRS.gov/FormsPubs or IRS.gov/
OrderForms.

Photographs of Missing Children

The Internal Revenue Service is a proud partner with the
National Center for Missing & Exploited Children®
(NCMEC). 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
Who Must File

Plan administrators of plans subject to the vesting standards
of section 203 of ERISA must file Form 8955-SSA. For
example, the plan administrator of a section 403(b) plan that
is subject to the vesting standards of section 203 of ERISA

Cat. No. 52730V

Using Extension of Time To File Federal Income
Tax Return

must file a Form 8955-SSA for the plan's deferred vested
participants. A plan administrator is not required to report a
separated participant if the participant's deferred vested
benefits are attributable to an annuity contract or custodial
account that is not required to be treated as part of the
section 403(b) plan assets for purposes of the reporting
requirements of ERISA Title I, as set forth in the Department
of Labor (DOL) Field Assistance Bulletin (FAB) 2009-02. For
this exception to apply:
1. The contract or account would have to have been
issued to a current or former employee before January 1,
2009;
2. The employer would have to have ceased having any
obligation to make contributions (including employee salary
reduction contributions), and in fact ceased making
contributions to the contract or account before January 1,
2009;
3. All the rights and benefits under the contract or
account would have to be legally enforceable against the
issuer or custodian by the participant without any
involvement by the employer; and
4. The participant would have to be fully vested in the
contract or account.

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 after 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 retained with the plan's
records.

Note. A tax-exempt organization filing Form 8868 to request
an extension of time to file a Form 990 series return is
automatically granted an extension of time to file Form
8955-SSA until the extended due date of filing their Form 990
series return if all conditions listed above are met.
Be sure to check the “automatic extension” box on Part I,
line C, at the top of the form. 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 more than 91/2 months beyond the close of the plan
year.

For more information, please see DOL FAB 2009-02 at
www.dol.gov.

Other Extensions of Time To File

Sponsors and administrators of government, church, and
other plans that are not subject to the vesting standards of
section 203 of ERISA (including plans that cover only owners
and their spouses or cover only partners and their spouses)
may elect to file Form 8955-SSA voluntarily. See the
instructions for Part I, line A.

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.”

Note. If the 2021 Form 5500 is the final return/report of the
plan, the Form 8955-SSA filed for the 2021 plan year must
report information on deferred vested participants, including
reporting that previously reported deferred vested
participants are no longer deferred vested participants.

Amended Registration Statement

When To File

File a 2021 Form 8955-SSA to correct errors and/or
omissions in a previously filed statement. 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.

In general, 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 (plus extensions). This due date
may be extended under some circumstances. See Extension
of Time To File below.

A full and complete Form 8955-SSA must be filed to
correct any such errors and/or omissions. For example, a full
and complete Form 8955-SSA must be filed if the plan
administrator determines that incorrect information was
provided for a single plan participant.

If the filing due date falls on a Saturday, Sunday, or legal
holiday, Form 8955-SSA may be filed on the next day that is
not a Saturday, Sunday, or legal holiday.

Extension of Time To File

It is important to use a 2021 Form 8955-SSA to report
revisions to a participant's information previously filed on a
Form 8955-SSA or a Schedule SSA (Form 5500). Because
the SSA provides information that it has on file to individuals
who file for benefits, if this information is not up to date, the
individual may contact the plan administrator to resolve the
difference.

Using Form 5558

If filing Form 8955-SSA under an extension of time based on
the filing of Form 5558, Application for Extension of Time To
File Certain Employee Plan Returns, check the appropriate
box on Form 8955-SSA, Part I, line C. A one-time extension
of time to file Form 8955-SSA may be obtained by filing Form
5558 on or before the normal due date (not including any
extensions) of Form 8955-SSA. See the instructions for Form
5558. You must file Form 5558 with the Department of the
Treasury, Internal Revenue Service Center, Ogden, UT
84201-0045. Because approved copies of Form 5558 will not
be returned to the filer, you should retain a copy of the Form
5558 that is filed.

Prior Year Statement

Although Schedule SSA (Form 5500) was previously used to
satisfy the reporting requirements of section 6057(a) for plan
years prior to January 1, 2009, the Schedule SSA (Form
5500) should no longer be filed under any circumstances.
(See Announcement 2011-21, 2011-12 I.R.B. 567.) Instead,
Form 8955-SSA should be filed for all plan years, including
delinquent returns for plan years before 2009. If a paper 2021

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Instructions for Form 8955-SSA (2021)

1. Is paid some or all of the deferred vested retirement
benefit (see the Caution),
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.

Form 8955-SSA is used to satisfy filing obligations for plan
years before 2009, complete Part I plan year beginning and
plan year ending dates for the appropriate plan year filed.
Forms 8955-SSA for prior years should be sent to the same
address as the 2021 Form 8955-SSA. See Where To File
below.

If payment of the deferred vested retirement benefit
ceases before ALL of the participant's vested benefit
CAUTION is paid to the participant or beneficiary, information
on the participant's remaining benefit shall be filed on the
Form 8955-SSA filed for the plan year following the last plan
year within which the payment ceased.

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.

Transfer of a Participant's Benefit to
the Plan of a New Employer

When the benefit of a separated participant with deferred
vested benefits is transferred from one plan to the plan of a
new employer:
1. The new plan administrator must complete a Form
8955-SSA using Entry Code C for Part III, line 9, column (a),
and specifying the previous sponsor’s EIN in column (h) and
the previous plan number in column (i) to complete the
transfer to the plan.
Note. In the rare case that the previous plan sponsor’s EIN
and previous plan number are not available, the new plan
administrator should complete a Form 8955-SSA using Entry
Code A for Part III, line 9, column (a).
2. The previous plan administrator must complete a Form
8955-SSA using Entry Code D for Part III, line 9, column (a),
to remove the information previously reported under the plan
for deferred vested participants.

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 a deferred vested
participant on the Form 8955-SSA filed for the plan year in
which the participant separates from service under the plan if
you want to report earlier. Do not report a participant more
than once unless you are revising or updating information on
a prior Form 8955-SSA or Schedule SSA (Form 5500). See
the Specific Instructions for Part III, line 9, codes B, C, or D.
For purposes of determining when to report a separated
participant, a single employer plan is a plan to which only one
employer contributes. A single employer plan includes a plan
maintained by:
• A controlled group of corporations that are treated as a
single employer under section 414(b),
• Trades or businesses under common control that are
treated as a single employer under section 414(c), and
• An affiliated service group that is treated as a single
employer under section 414(m).

Where To File

If Form 8955-SSA is sent by United States mail, send the
complete form to:
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201-0024

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.

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. Go to
IRS.gov/PDS for the current list of designated services.
The PDS can tell you how to get written proof of the
mailing date.
Private delivery services must send Form 8955-SSA to:

For these purposes, a multiemployer plan and a
multiple-employer plan are each treated as a plan to which
more than one employer contributes.
In general, information about 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 1-year
breaks in service. Consecutive 1-year breaks in service are
defined in the plan for purposes of determining a participant’s
vesting percentage. The participant may be reported earlier
on the Form 8955-SSA filed for the plan year in which the
participant completed the first 1-year break in service.

Internal Revenue Submission Processing Center
1973 Rulon White Blvd.
Ogden, UT 84201

How To File

Follow the line-by-line instructions to complete Form
8955-SSA. Answer all questions about the plan, unless
otherwise specified.

When Not To Report a Participant

A participant who has not been previously reported 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:

Instructions for Form 8955-SSA (2021)

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• Check your information to avoid errors.
• Complete all applicable lines on the form unless otherwise

Form 8955-SSA must be filed with the IRS. Form
8955-SSA is NOT open to public inspection. DO
CAUTION NOT attach a Form 8955-SSA (or a previous year's
Schedule SSA (Form 5500)) to a Form 5500 or Form
5500-SF required to be filed with the Department of Labor
(DOL) filing system (“EFAST2”).

!

specified.
• Print all information necessary in the specific fields
provided on the form.
• Do not mark on or near any barcode.
• Do not use glue or other sticky substances on the paper
form.
• 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 Form 8955-SSA using the address specified in the
instructions under Where To File, earlier.
• Use only whole dollars. Round off cents to whole dollars.
Drop any amount less than 50 cents and increase any
amount from 50 to 99 cents to the next higher dollar.

Mandatory electronic filing. For 2013 and prior years,
filers had the option of filing Form 8955-SSA electronically.
Beginning with the 2014 Form 8955-SSA, however, some
filers are now required to file the form electronically. A filer
must electronically file the 2021 Form 8955-SSA if the filer is
required to file 250 returns of any type during the calendar
year that includes the first day of the plan year. “Returns” for
this purpose include information returns (for example, Forms
W-2 and 1099), income tax returns, employment tax returns
(including quarterly Forms 941), and excise tax returns. If a
filer is required to file a Form 8955-SSA electronically but
does not, the filer is considered not to have filed the form
even if a paper return is submitted.

Penalties

Section 6652(d)(1) imposes a penalty for failure to file a
registration statement (including failure to include all required
participants). The penalty is $10 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
$50,000, is imposed on the person failing to properly file
unless it is shown the failure is due to reasonable cause.

Note. The instructions are not updated for the applicable
number changes for the mandatory electronic filing
requirement as amended by the Taxpayer First Act of 2019
pending guidance.
The requirement to file the 2021 Form 8955-SSA
electronically does not apply to filers filing for relief under
Notice 2014-35, 2014-23 I.R.B. 1072 (relating to filers who
qualify for relief under the Department of Labor’s Delinquent
Filer Voluntary Compliance Program). See Regulations
section 301.6057-3 for more information on the mandatory
electronic filing of Form 8955-SSA.
The IRS may waive the requirements to file Form
8955-SSA electronically in cases of undue economic
hardship. For information on filing a request for a hardship
waiver, see Rev. Proc. 2015-47, 2015-39 I.R.B. 419,
available at IRS.gov/irb/2015-39_IRB/ar16.html, and
IRS.gov/Retirement-Plans/FAQs-Regarding-Form-8955SSA.

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, section 6652(d)(2) imposes a
penalty of $10 for each day during which such failure occurs.
The penalty, up to a maximum of $10,000, is imposed on the
person failing to so file unless it is shown the failure is due to
reasonable cause.
The Code provides that each plan administrator required
to file a registration statement must, before the expiration of
the time prescribed for the filing of the form, also furnish to
each affected participant an individual statement setting forth
the information required to be contained in the form. Section
6690 imposes a penalty of $50 on the person required to
furnish the individual statement to each affected participant
for each willful failure to furnish the statement or a willful
furnishing of a false statement.

Electronic and paper filing. You can:
• Use SSA-approved software to complete and
electronically file a Form 8955-SSA. For more information, go
to IRS.gov, search for and select “Form 8955-SSA
Resources,” and then select “Approved Software Vendors
Form 8955-SSA.”
• Use a personal computer to complete the online fillable
Form 8955-SSA on the IRS website at
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 from the IRS.
• Use a printed Form 8955-SSA ordered from the IRS
website at IRS.gov/OrderForms. When completing the form,
use as many pages 2 of the Form 8955-SSA as necessary to
list separated participants and number the pages in
sequential order.

Specific Instructions
PART I

Enter the calendar or fiscal year beginning and ending dates
of the plan year (not to exceed 12 months in length) for which
you are reporting information. Express the dates in numerical
month, day, and year in the following order: (MMDDYYYY).
For a plan year of less than 12 months (short plan year),
enter 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 a change in
accounting period or the complete distribution of the plan's
assets.

Note. Remember to use additional pages 2 of the 2021
Form 8955-SSA only if additional pages are needed to add
separated participants. Do not use nonstandard pages 2.

Line A. Check this box if you are electing to file this form
voluntarily. The plan administrators of plans, such as
governmental plans and non-electing church plans, not
subject to the vesting standards of section 203 of ERISA are
not required to file this form but may elect to do so. If such a
plan administrator so elects, the plan administrator is

Processing tips. To reduce the possibility of
correspondence and penalties:
• Sign and date Form 8955-SSA.
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Instructions for Form 8955-SSA (2021)

Form 8955-SSA. (See the 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).

encouraged to provide as much information as possible, but
no specific requirements are imposed.
Note. Only the plan administrators of plans subject to the
vesting standards of section 203 of ERISA must file the Form
8955-SSA.

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 B. Check this box if this Form 8955-SSA amends a
previously filed Schedule SSA (Form 5500) or Form
8955-SSA.

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 on lines 2f through 2l.

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, earlier, for additional information regarding
special extensions.

Line 2f. Enter the plan sponsor's street address. A post
office box may be entered if the Post Office does not deliver
mail to the plan 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.

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 2j. Enter the foreign province or state, if applicable.
Line 2k. Enter the foreign country, if applicable.
Line 2l. Enter the foreign postal code, if applicable. Leave
the U.S. state and ZIP code blank if completing line 2k or
line 2l.

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 number that the employer or
plan administrator assigned to the plan and uses to file the
plan's Form 5500 return/report.

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 lines 3b
through 3k 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.

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
established or maintain the plan (in the case of a plan
established or maintained jointly by one or more employers
and one or more employee organizations, or by two or more
employers).

Note. Employees of the plan sponsor who perform
administrative functions for the plan are generally not plan
administrators 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.

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. The plan
administrator of a plan maintained by a controlled group of
corporations should enter the name of the member of the
controlled group that is entered on the Form 5500 return/
report as the plan sponsor. The same name must be used in
all subsequent filings of the Form 8955-SSA for the
multiple-employer plan or controlled group. (See the
instructions for line 5 about changes in sponsorship.)

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
administrator, enter “C/O” followed by the third party's name
and complete the applicable mailing address on lines 3e
through 3k.

Line 2b. Enter the sponsor's nine-digit EIN. Do not use a
social security number (SSN). Sponsors without an EIN must
apply for one as soon as possible.
EINs are issued by the IRS. You can apply for an EIN:
• Online — Go to the IRS website at IRS.gov/EIN. 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.)
• By mailing or faxing Form SS-4, Application for Employer
Identification Number.
A multiple-employer plan or plan of a controlled group of
corporations should use the EIN of the sponsor identified on
line 2a. The EIN must be used in all subsequent filings of

Instructions for Form 8955-SSA (2021)

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 postal code, if applicable. Leave
the U.S. state and ZIP code blank if completing line 3j or
line 3k.
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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
administrator's name and EIN as they appeared on the most
recently filed Schedule SSA (Form 5500) or Form 8955-SSA.

!

CAUTION

Code Use this code for a participant not previously
A
reported. Also, complete columns (b) through
(g), as applicable.
Code Use this code for a participant previously
B
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), as applicable. 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 Use this code for a participant previously
C
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 Use this code for a participant previously
D
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). Participants should not be reported under
Code D merely because they return to the
service of the plan sponsor.

Failure to indicate on line 4 that a plan administrator
was previously identified by a different name or EIN
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 three-digit plan number as they appeared on the
most recently filed Schedule SSA (Form 5500) or Form
8955-SSA.

!

CAUTION

Failure to indicate on line 5 that a plan sponsor was
previously identified by a different name or EIN could
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 2020 plan
year and who were not previously reported. 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 2021 plan year and who were not previously
reported.
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 under the plan in
the 2021 plan year and who are reported in Part III of 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
under the plan in 2021 or who completed the first 1-year
break in service in the 2021 plan year and who are reported
in Part III of this form. See When To Report a Separated
Participant.

Line 9, column (b). Enter the full nine-digit SSN of each
participant listed. Please do not enter only the last four digits
of the SSN. 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 checkmark 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 that 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
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).

Do not include any participants on line 6a or 6b who
were previously reported on a Form 8955-SSA or a
CAUTION Schedule SSA (Form 5500). Accordingly, only those
participants who are listed with an Entry Code A on page 2
should be included on line 6a or 6b.

!

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. Form 8955-SSA must be signed and dated by
the plan sponsor and by the plan administrator. If the plan
administrator and the plan sponsor are the same person,
include only the signature as plan administrator on the form.
If more than one page 2 of the form is filed for one plan, only
one page 1 of Form 8955-SSA should be signed and filed
with the pages 2 for the plan.

PART III

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,

Enter the name of the plan, the plan number, and the plan
sponsor's EIN at the top of each page 2.
Line 9, column (a). Enter the appropriate code from the
following list.
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Instructions for Form 8955-SSA (2021)

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).

Privacy Act and Paperwork Reduction Act Notice. We
ask for the information on this form to carry out the Internal
Revenue laws of the United States. Sections 6057 and 6109
require you to provide the information requested on this form.
We need it to determine whether the plan properly accounts
for the deferred vested retirement benefits of separated
participants. Failure to provide this information, or providing
false or fraudulent information, may subject you to penalties.

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

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
or records relating to a form or its instructions must be
retained as long as their contents may become material in
the administration of any Internal Revenue law. Generally,
tax returns and return information are confidential, as
required by section 6103.

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

However, section 6103 authorizes disclosure of the
information to others. Pursuant to section 6057(d), we will
disclose this information to the Social Security Administration
for use in administering the Social Security Act. This
information may also be disclosed to the Department of
Justice for civil or criminal litigation, to the Department of
Labor or the Pension Benefit Guarantee Corporation for use
in administering ERISA, and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for
use in administering their tax laws. It may also be disclosed
to other countries under a tax treaty, to federal and state
agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to combat
terrorism.

Line 9, column (f). For a defined benefit plan, enter the
amount (in whole dollars) of the periodic payment that a
participant is entitled to receive.
In general, a deferred vested benefit under a defined
benefit plan would be reported under line 9, column (f), as
the periodic payment that the participant is entitled to
receive. The plan administrator may, however, report a
different form of benefit if the plan administrator considers it
more appropriate. For example, the plan administrator of a
cash balance plan may report a participant's benefit as the
participant's hypothetical account balance. In that case, the
plan administrator may enter Code A (a single sum) in
column (d) and Code A (a lump sum) in column (e).
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.

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 suggestions for making this form simpler, we
would be happy to hear from you. You can send us
comments from IRS.gov/FormComments. Or you can write to
the Internal Revenue Service, Tax Forms and Publications
Division, 1111 Constitution Ave. NW, IR-6526, Washington,
DC 20224. Do not send Form 8955-SSA to this address.
Instead, see Where To File, earlier.

Line 9, column (g). For defined contribution plans, enter
the value (in whole dollars) of the participant's account.
Line 9, columns (h) and (i). Show the EIN and plan
number of the plan under which the participant was
previously reported.

Instructions for Form 8955-SSA (2021)

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