Form 8955-Ssa - Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits - 2010 Page 2

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Form 8955-SSA Instructions

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Form 8955-SSA (2010)

Page # of ##

Page 2.

Name

Plan Number

EIN

of plan

PART III

Participant Information - enter all requested information

9 Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits who:

Code A

—

has not previously been reported.

Code B

—

has previously been reported under the above plan number, but whose previously reported information requires revisions.

Code C

—

has previously been reported under another plan, but who will be receiving benefits from the plan listed above instead.

Code D

—

has previously been reported under the above plan number, but whose benefits have been paid out or who is no longer entitled to those deferred vested benefits.

Use with entry code "A", "B", "C", or "D"

Use with entry code "A" or "B"

Entry code "C" only

Enter code for nature

(b)

Amount of vested benefit

(h)

(i)

(

c) Name of Participant (See instructions.)

(a)

and form of benefit