Form 5558 - Application For Extension Of Time To File Certain Employee Plan Returns

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5558
Application for Extension of Time
OMB No. 1545-0212
Form
To File Certain Employee Plan Returns
(Rev. August 2012)
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
File With IRS Only
Department of the Treasury
Information about Form 5558 and its instructions is at
Internal Revenue Service
Part I
Identification
A
B
Name of filer, plan administrator, or plan sponsor (see instructions)
Filer’s identifying number (see instructions)
Employer identification number (EIN) (9 digits XX-XXXXXXX)
Number, street, and room or suite no. (If a P.O. box, see instructions)
Social security number (SSN) (9 digits XXX-XX-XXXX)
City or town, state, and ZIP code
C
Plan year ending—
Plan
Plan name
number
DD
YYYY
MM
Part II
Extension of Time To File Form 5500 Series, and/or Form 8955-SSA
Check this box if you are requesting an extension of time on line 2 to file the first Form 5500 series return/report for the plan listed
1
in Part 1, C above.
2
I request an extension of time until
/
/
to file Form 5500 series (see instructions).
Note. A signature IS NOT required if you are requesting an extension to file Form 5500 series.
3
I request an extension of time until
/
/
to file Form 8955-SSA (see instructions).
Note. A signature IS NOT required if you are requesting an extension to file Form 8955-SSA.
The application is automatically approved to the date shown on line 2 and/or line 3 (above) if: (a) the Form 5558 is filed on or before
the normal due date of Form 5500 series, and/or Form 8955-SSA for which this extension is requested, and (b) the date on line 2
and/or line 3 (above) is not later than the 15th day of the third month after the normal due date.
Part III
Extension of Time To File Form 5330 (see instructions)
4
I request an extension of time until
/
/
to file Form 5330.
You may be approved for up to a 6 month extension to file Form 5330, after the normal due date of Form 5330.
a
Enter the Code section(s) imposing the tax
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a
b
Enter the payment amount attached .
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b
c
For excise taxes under section 4980 or 4980F of the Code, enter the reversion/amendment date .
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c
5
State in detail why you need the extension:
Under penalties of perjury, I declare that to the best of my knowledge and belief, the statements made on this form are true, correct, and complete, and that I am authorized
to prepare this application.
Signature
Date
5558
Form
(Rev. 8-2012)
Cat. No. 12005T

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