Form 8955-Ssa - Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits - 2010

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Form 8955-SSA Instructions

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Annual Registration Statement Identifying Separated

OMB No. 1545-2187

8955-SSA

Form

Participants With Deferred Vested Benefits

Department of the Treasury

Under Section 6057 of the Internal Revenue Code

This Form is NOT Open

Internal Revenue Service

to Public Inspection

PART I

Annual Statement Identification Information

For the plan year beginning

, and ending

Check here if plan is a government, church, or other plan that elects to voluntarily file Form 8955-SSA. (See instructions.)

Check here if this is an amended registration statement.

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

2a Plan sponsor’s name

2b Employer Identification Number

(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)

a. Participants who separated with a deferred vested benefit required to be reported on this Form 8955-SSA . . . . . . . . . .

b. Participants who separated with a deferred vested benefit voluntarily reported on this Form 8955-SSA

in the same year as the separation occurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total number of participants reported on lines 6a and 6b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Did the plan administrator provide an individual statement to each participant required to receive a statement? . . . . . . . . .

Yes

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 (2010)