Publication 1635 - Understanding Your Employer Identification Numbers Page 23
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32Complete Third Party Designee only if you want to authorize the named individual to receive the EIN and
answer questions about the completion of this form. If N/A, complete the Name and Title areas only.
Name and Title: Print the plan administrator’s name and title
Telephone Number: Enter the telephone number where we can reach you if we have questions about your
application.
Signature: A responsible and duly authorized member or officer with knowledge of plan affairs must sign.
8. Employee Plans
Line 1
Always enter the name of the plan.
Line 2
Enter the name of the trustee.
Line 3
N/A
Line 4a
Enter the trustee’s mailing address.
Line 4b
Enter the trustee’ s city, state, and zip code.
Lines 5a
and 5b Enter only if different from the mailing address.
Line 6
Enter the county and state where the employee plan is located.
Line 7a
Enter name of responsible person for the plan.
Line 7b
Enter SSN of responsible person for the plan.
Line 8a
Check “Trust” or “Other” and write in “Employee Plan”.
Line 8b
N/A
Line 9
Check “Created a pension plan”. Enter the type of plan created.
Line 10
Enter the starting date of the plan.
Line 11
Enter the last month of the plan’s accounting year.
Line 12
Enter the date the plan began or will begin to pay wages to employees. If you have
no employees, enter N/A.
Line 13
Enter the highest number of employees you plan to hire within the next 12 months.
If none, enter 0.
Line 14
Check the “other” box and enter the exact type of plan you plan to operate.
Line 15
Enter the principal line of merchandise that the plan provided.
Line 16a:
Check “Yes” or “No” to whether or not you have ever applied for an EIN.
If “Yes”, complete lines 16b and 16c.
If “No”, skip 16b and 16c.
Line 16b
If you checked “Yes” on 16a, enter applicants’ s legal name and trade name shown on
prior application if different from line 1 or 2 of Form SS-4.
Line 16c
If you checked “Yes” on Line 16a, give approximate date when application was filed and the city
and state where it was filed. Enter previous EIN number if known.
Complete Third Party Designee only if you want to authorize the named individual to receive the EIN and
answer questions about the completion of this form. If N/A, complete the Name and Title area only.
Name and Title: Print your name and title (i.e., owner, president, vice-president, etc.)
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Parent category: Financial