Form 8955-Ssa Annual Registration Statement

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1807
Annual Registration Statement Identifying Separated
OMB No. 1545-2187
8955-SSA
Form
Participants With Deferred Vested Benefits
Department of the Treasury
This form is required to be filed under section 6057 of the Internal Revenue Code.
This Form is NOT Open
Internal Revenue Service
► Information about Form 8955-SSA and its instructions is at
to Public Inspection
PART I
Annual Statement Identification Information
For the plan year beginning
, and ending
A
Check here if plan is a government, church, or other plan that elects to voluntarily file Form 8955-SSA. (See instructions.)
B
Check here if this is an amended registration statement.
C
Check the appropriate box if filing under:
Form 5558
Automatic extension
Special extension (enter description)
PART II
Basic Plan Information - enter all requested information
1a Name
1b Plan Number (PN)
of plan
Plan Sponsor Information
2b Employer Identification Number
2a Plan sponsor’s name
(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 Foreign 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 Foreign 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
EIN
Plan Number (PN)
6a Participants who separated with a deferred vested benefit required to be reported on this Form 8955-SSA . . . . . . . . . . .
6a
6b Participants who separated with a deferred vested benefit voluntarily reported on this Form 8955-SSA
in the same year as the separation occurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6b
7
Total number of participants reported on lines 6a and 6b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
8
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.
Signature of plan sponsor
Date signed
Signature of plan administrator
Date signed
Sign
Here
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 52729U
Form 8955-SSA (2015)

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