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Line 4, box (b). Enter the exact social security number (SSN)

Type of Payment Code

of each participant listed. If the participant is a foreign national

employed outside the United States who does not have an

A Lump sum

SSN, enter the word ‘‘FOREIGN.’’

B Annually

C Semiannually

Line 4, box (c). Enter each participant’s name exactly as it

appears on the participant’s social security card. Do not enter

D Quarterly

periods; however, initials, if on the social security card, are

E Monthly

M Other

permitted. Space is available for the first eleven characters of

the participant’s first name, one for their middle initial, and the

first fifteen characters of their last name. If the participant does

Line 4, box (f). For a defined benefit plan, enter the amount of

not have a middle initial, leave the space for the middle initial

the periodic payment that a participant is entitled to receive

blank.

under line 4, box (f).

Line 4, box (d). From the following list, select the code that

For a plan to which more than one employer contributes, if

describes the type of annuity that will be provided for the

the amount of the periodic payment cannot be accurately

participant. Enter the code that describes the type of annuity

determined because the plan administrator does not maintain

that normally accrues under the plan at the time of the

complete records of covered service, enter an estimated

participant’s separation from service covered by the plan (or for

amount.

a plan to which more than one employer contributes at the time

the participant incurs the second consecutive 1-year break in

Line 4, box (g). For a defined contribution plan, if the plan

service under the plan).

states that a participant’s share of the fund will be determined

on the basis of units, enter the number of units credited to the

participant.

Type of Annuity Code

A A single sum

If, under the plan, participation is determined on the basis of

B Annuity payable over fixed number of years

shares of stock of the employer, enter the number of shares

C Life annuity

and add the letters ‘‘S’’ to indicate shares. A number without the

D Life annuity with period certain

‘‘S’’ will be interpreted to mean units.

E Cash refund life annuity

Line 4, box (h). For defined contribution plans, enter the value

F Modified cash refund life annuity

of the participant’s account at the time of separation.

G Joint and last survivor life annuity

Line 4, boxes (i) and (j). Show the EIN and plan number of

M Other

the plan under which the participant was previously reported.

Line 4, box (e). From the following list, select the code that

Signature. This form must be signed by the plan

describes the benefit payment frequency during a 12-month

administrator. If more than one Schedule SSA is filed for one

period.

plan, only the initial page one should be signed.

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Instructions for Schedule SSA (Form 5500)

Instructions For Schedule Ssa (Form 5500) - Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits - 2002 Page 2

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