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Line 9, column (e). From the following list, select the code

the participant’s service. Check the box next to a

participant’s name if:

that describes the benefit payment frequency during a

12-month period.

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

Type of Payment Code

2. The plan administrator is unable to determine from the

A Lump sum

records of the participant’s service if the participant is vested

B Annually

in any deferred retirement benefit but there is a significant

C Semiannually

likelihood that the participant is vested in such a benefit. See

D Quarterly

Regulations section 1.6057-1(b)(3).

E Monthly

Line 9, column (d). From the following list, select the code

M Other

that describes the type of annuity that will be provided for

the participant. Enter the code that describes the type of

Line 9, column (f). For a defined benefit plan, enter the

annuity that normally accrues under the plan at the time of

the participant’s separation from service covered by the plan

amount of the periodic payment that a participant is entitled

to receive.

(or for a plan to which more than one employer contributes

at the time the participant incurs the second consecutive

For a multiemployer plan, if the amount of the periodic

one-year break in service under the plan).

payment cannot be accurately determined because the plan

Type of Annuity Code

administrator does not maintain complete records of

A A single sum

covered service, enter an estimated amount.

B Annuity payable over fixed number of years

C Life annuity

Line 9, column (g). For defined contribution plans, enter

D Life annuity with period certain

the value of the participant’s account.

E Cash refund life annuity

F Modified cash refund life annuity

Line 9, columns (h) and (i). Show the EIN and plan

G Joint and last survivor life annuity

number of the plan under which the participant was

M Other

previously reported.

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form to carry out the internal revenue laws. Code section 6057 requires 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.

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 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.

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, 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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Instructions For Form 8955-Ssa - Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits - Internal Revenue Service - 2009 Page 6

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