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penalty of $1 for each day during which such failure occurs.

the employer, for a plan that a single-employer

The penalty, up to a maximum of $1,000, is imposed on the

established or maintains;

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person failing to so file unless it is shown the failure is due to

the employee organization in the case of a plan of an

reasonable cause.

employee organization; or

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the association, committee, joint board of trustees, or

The Code requires that each plan administrator required

other similar group or representatives of the parties who

to file a registration statement must, before the expiration of

established or maintain the plan (in the case of a plan

the time prescribed for the filing of the form, also furnish to

established or maintained jointly by one or more employers

each affected participant an individual statement setting

and one or more employee organizations, or by two or more

forth the information required to be contained in the form. A

employers).

penalty of $50 is imposed on the person required to furnish

Note. In the case of a multiple employer plan, if an

the statement to each affected participant for each willful

association or similar entity is not the sponsor, enter the

failure to furnish the statement or a willful furnishing of a

name of a participating employer as sponsor. The plan

false statement.

administrator of a plan maintained by a controlled group of

corporations should enter the name of the member of the

Specific Instructions

controlled group that is entered on the Form 5500 series

return/report as the plan sponsor. The same name must be

used in all subsequent filings of the Form 8955-SSA for the

PART I

multiple-employer plan or controlled group (see instructions

Enter the calendar or fiscal year beginning and ending dates

for line 5 about changes in sponsorship).

of the plan year (not to exceed 12 months in length) for

Line 2b. Enter the sponsor’s nine-digit EIN. Do not use a

which you are reporting information. Express the dates in

social security number (SSN). Sponsors without an EIN

numerical month, day, and year in the following order

must apply for one as soon as possible.

(“MMDDYYYY”).

EINs are issued by the IRS. To apply for an EIN:

Enter the beginning and ending dates for the 2009 plan

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Mail or fax Form SS-4, Application for Employer

year when combining information for the 2009 and 2010

Identification Number, obtained by calling 1-800-TAX-FORM

plan years. For example, a plan that reports on a calendar

(1-800-829-3676) or at the IRS website at IRS.gov.

year basis and combines information for the 2009 and 2010

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Call 1-800-829-4933 to receive your EIN by telephone.

plan years should enter January 1, 2009 as the beginning

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Select the Online EIN Application link at IRS.gov. The EIN

date and December 31, 2009 as the end date.

is issued immediately once the application information is

For a plan year of less than 12 months (short plan year),

validated. (The online application process is not yet

insert the short plan year beginning and ending dates on the

available for corporations with addresses in foreign

line provided at the top of the form. For purposes of this

countries.)

form, the short plan year ends on the date of the change in

A multiple-employer plan or plan of a controlled group of

accounting period or upon the complete distribution of the

corporations should use the EIN of the sponsor identified in

plan’s assets.

line 2a. The EIN must be used in all subsequent filings of

Line A. Check this box if you are voluntarily electing to file

the Form 8955-SSA. (See instructions for line 5 about

this form. The plan administrators of plans subject to the

changes in EIN.)

vesting standards of section 203 of ERISA must file this

If the plan sponsor is a group of individuals, get a single

Form 8955-SSA.

EIN for the group (providing the group name).

Note. The plan administrators of other plans (for instance,

Line 2c. Enter the plan sponsor’s trade name if that trade

plan administrators of governmental plans and non-electing

name is different from the plan sponsor’s name entered on

church plans, which are not subject to ERISA section 203),

line 2a.

however, are not required to file this form but may elect to

Line 2e. If you want a third party to receive mail for the

do so. If such a plan administrator so elects, the plan

plan, enter “C/O” followed by the third party’s name and

administrator is encouraged to provide as much information

complete the applicable mailing address in lines 2f through

as possible, but no specific requirements are imposed.

2l.

Line B. Check this box if this Form 8955-SSA amends a

Line 2f. Enter the sponsor’s street address. A post office

previously filed Schedule SSA (Form 5500) or Form

box may be entered if the Post Office does not deliver mail

8955-SSA.

to the sponsor’s street address.

Line C. Check the appropriate box if an extension of time

Line 2g. Enter the name of the city.

has been filed using Form 5558, or if an automatic or special

Line 2h. Enter the two-character abbreviation for the U.S.

extension has been granted. If a special extension has been

state or possession.

granted, enter the description of the special extension

Line 2j. Enter the foreign province or state, if applicable.

exactly as it is listed in the announcement. See Other

Extensions of Time To File for additional information

Line 2k. Enter the foreign country, if applicable.

regarding special extensions.

Line 2l. Enter the foreign routing code, if applicable. Leave

the U.S. state and zip code blank if completing line 2k or line

PART II

2l.

Please verify that the employer identification number (EIN)

Line 3a. Enter the plan administrator’s name. Enter “Same”

and plan number (PN) being used on this Form 8955-SSA

if the plan administrator identified on line 3a is the same as

are correct for this plan.

the plan sponsor identified on line 2a and leave the

Line 1a. Enter the formal name of the plan or enough

remainder of line 3a blank, and lines 3b through 3c blank.

information to identify the plan. Abbreviate if necessary.

Plan administrator for this purpose means:

Line 1b. Enter the three-digit plan number that the

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The person or group of persons specified as the

employer or plan administrator assigned to the plan uses for

administrator by the instrument under which the plan is

filing the Form 5500 series.

operated;

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Line 2a. Enter the name of the plan sponsor. The term

The plan sponsor/employer if an administrator is not so

“plan sponsor” means:

designated; or

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Instructions For Form 8955-Ssa - Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits - Internal Revenue Service - 2009 Page 4

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