Form 8955-SSA, Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits

2013

Department of the Treasury
Internal Revenue Service

Instructions for Form
8955-SSA

Annual Registration Statement Identifying Separated Participants With Deferred
Vested Benefits
Section references are to the Internal Revenue Code,
unless otherwise noted. ERISA refers to the Employee
Retirement Income Security Act of 1974.

Purpose of Form

Form 8955-SSA, the designated successor to
Schedule SSA (Form 5500), is used to satisfy the
reporting requirements of section 6057(a). Form
8955-SSA is a stand-alone reporting form filed with the
Internal Revenue Service (IRS). See Where To File. Do
not file Form 8955-SSA with the Form 5500, Annual
Return/Report of Employee Benefit Plan, or Form
5500-SF, Short Form Annual Return/Report of Small
Employee Benefit Plan.
Use Form 8955-SSA to report information about
separated participants with deferred vested benefits
under the plan. Required information includes participants
who have a deferred vested benefit under the plan and:
separated from service covered by the plan;
were reported as deferred vested participants on
another plan's filing if their benefits were transferred (other
than in a rollover) to the plan during the covered period;
previously were reported under the plan but have been
paid out or are no longer entitled to those deferred vested
benefits; or
previously were reported under the plan but whose
information is being corrected.
The information reported on Forms 8955-SSA is
generally given to the Social Security Administration
(SSA). The SSA provides the reported information to
separated participants when they file for social security
benefits.
Note. The SSA no longer processes nonstandard pages
2. Report information about separated participants only
on page 2 of Form 8955-SSA. If additional space is
needed for separated participants, use additional pages 2
only. Do not add another page 1 of Form 8955-SSA,
spreadsheets, or other nonstandard formats.
A Form 8955-SSA need not be filed for a year if no
information is required to be provided for that year by
these instructions.
The Form 8955-SSA may be filed electronically through
the IRS Filing Information Returns Electronically (FIRE)
system or on paper. For more information regarding
electronic and paper filing, see How To File.
The IRS and SSA encourage all filers to file Form
8955-SSA electronically. Filing electronically saves time
and effort and helps ensure accuracy.
Reporting requirement. Under section 6057(b), plan
administrators must notify the Secretary of the Treasury of
Jan 15, 2014

certain changes to the plan and the plan administrator.
These changes are reported on the plan’s Form 5500
annual return/report. Plan administrators should report
these changes on the Form 5500 return/report for the plan
year in which the change occurs as indicated in the Form
5500 instructions.

Telephone Assistance

If you have questions and need assistance completing
this form, call the IRS Help Line at 1-877-829-5500 and
follow the directions as prompted. This toll-free telephone
service is available Monday through Friday.

How To Get Forms and Publications
Internet. You can access the IRS website 24 hours a
day, 7 days a week at IRS.gov to:
Download forms, instructions, and publications;
Order IRS products online;
Research your tax questions online;
Search publications online by topic or keyword; and
Sign up to receive local and national tax news by email.
By phone and in person. You can order forms and IRS
publications by calling 1-800-TAX-FORM
(1-800-829-3676). You can also get most forms and
publications at your local IRS office.

Photographs of Missing Children

The Internal Revenue Service is a proud partner with the
National Center for Missing and Exploited Children.
Photographs of missing children selected by the Center
may appear in instructions on pages that would otherwise
be blank. You can help bring these children home by
looking at the photographs and calling 1-800-THE-LOST
(1-800-843-5678) if you recognize a child.

General Instructions
Future developments. The IRS has created a page on
IRS.gov for information about Form 8955-SSA and its
instructions, at www.irs.gov/form8955ssa. Information
about any future developments affecting Form 8955-SSA
(such as legislation enacted after we release it) will be
posted on that page.

Who Must File

Plan administrators of plans subject to the vesting
standards of section 203 of ERISA must file Form
8955-SSA. For example, the plan administrator of a
section 403(b) plan that is subject to the vesting standards
of section 203 of ERISA must file a Form 8955-SSA for
the plan's deferred vested participants. A plan
administrator is not required to report a separated

Cat. No. 52730V

will not be returned to the filer, you should retain a copy of
the Form 5558 that is filed.

participant if the participant's deferred vested benefits are
attributable to an annuity contract or custodial account
that is not required to be treated as part of the section
403(b) plan assets for purposes of the reporting
requirements of ERISA Title I, as set forth in the
Department of Labor (DOL) Field Assistance Bulletin
(FAB) 2009-02. For this exception to apply,
1. The contract or account would have to have been
issued to a current or former employee before January 1,
2009;
2. The employer would have ceased having any
obligation to make contributions (including employee
salary reduction contributions), and in fact ceased making
contributions to the contract or account before January 1,
2009;
3. All the rights and benefits under the contract or
account would be legally enforceable against the issuer or
custodian by the participant without any involvement by
the employer; and
4. The participant would have to be fully vested in the
contract or account.

Using Extension of Time To File Federal Income
Tax Return

An automatic extension of time to file Form 8955-SSA
until the due date of the federal income tax return of the
employer will be granted if both of the following conditions
are met.
1. The plan year and the employer's tax year are the
same.
2. The employer has been granted an extension of
time to file its federal income tax return after the normal
due date for filing the Form 8955-SSA.
An extension of time granted by using this automatic
extension procedure CANNOT be extended further by
filing a Form 5558. It also cannot be extended more than
91 2 months beyond the close of the plan year.

Other Extensions of Time To File

The IRS may from time to time announce special
extensions of time under certain circumstances, such as
extensions for presidentially-declared disasters or for
service in, or in support of, the Armed Forces of the United
States in a combat zone. See IRS.gov for announcements
of special extensions. If you are relying on a special
extension, check the box on line C and enter the exact
language describing the announcement in the space
provided. For example, indicate “Disaster Relief
Extension” or “Combat Zone Extension.”

For more information, please see DOL FAB 2009-02,
www.dol.gov/ebsa.
Sponsors and administrators of government, church,
and other plans that are not subject to the vesting
standards of section 203 of ERISA (including plans that
cover only owners and their spouses) may elect to file the
Form 8955-SSA voluntarily. See the instructions for Part I,
line A.

Amended Registration Statement

Note. If the 2013 Form 5500 annual return/report is the
final return/report of the plan, the Form 8955-SSA filed for
the 2013 plan year must report information on deferred
vested participants, including reporting that previously
reported deferred vested participants are no longer
deferred vested participants.

File a 2013 Form 8955-SSA to correct errors and/or
omissions in a previously filed statement for the 2013 plan
year. Check the box for Part I, line B (“amended
registration statement”). The amended Form 8955-SSA
must conform to the requirements in the How To File
section.
A full and complete Form 8955-SSA must be filed to
correct any such errors and/or omissions. For example, a
full and complete Form 8955-SSA must be filed if the plan
administrator determines that incorrect information was
provided for a single plan participant.
It is important to use a 2013 Form 8955-SSA to report
revisions to a participant's information previously filed on a
Form 8955-SSA or a Schedule SSA (Form 5500).
Because SSA provides information that it has on file to
individuals who file for benefits, if this information is not
up-to-date, the individual may contact the plan
administrator to resolve the difference.

When To File

In general, if a Form 8955-SSA must be filed for a plan
year, it must be filed by the last day of the seventh month
following the last day of that plan year (plus extensions).
This due date may be extended under some
circumstances. See Extension of Time To File.

If the filing due date falls on a Saturday, Sunday, or
legal holiday, Form 8955-SSA may be filed on the next
day that is not a Saturday, Sunday, or legal holiday.

Extension of Time To File
Using Form 5558

Prior Year Statement

If filing under an extension of time based on the filing of
Form 5558, Application for Extension of Time To File
Certain Employee Plan Returns, check the appropriate
box on the Form 8955-SSA, Part I, line C. A one-time
extension of time to file the Form 8955-SSA (up to 21 2
months) may be obtained by filing Form 5558 on or before
the normal due date (not including any extensions) of the
Form 8955-SSA. See the instructions for Form 5558. You
must file the Form 5558 with the Department of the
Treasury, Internal Revenue Service Center, Ogden, UT
84201-0045. Because approved copies of the Form 5558

Although the Schedule SSA (Form 5500) was previously
used to satisfy the reporting requirements of section
6057(a) for plan years prior to January 1, 2009, the
Schedule SSA should no longer be filed under any
circumstances. (See Announcement 2011-21, 2011-12
I.R.B. 567.) Instead, Form 8955-SSA should be filed for all
plan years, including delinquent returns for plan years
before 2009. If a paper 2013 Form 8955-SSA is used to
satisfy filing obligations for plan years before 2009,
complete Part I 'plan year beginning and plan year ending'
-2-

1. Is paid some or all of the deferred vested retirement
benefit (see the Caution below),
2. Returns to service covered by the plan and/or
accrues additional retirement benefits under the plan, or
3. Forfeits all the deferred vested retirement benefit.

dates for the appropriate plan year filed. Forms 8955-SSA
for prior years should be sent to the same address as the
2013 Form 8955-SSA. See Where To File.

When To Report a Separated
Participant

If payment of the deferred vested retirement
benefit ceases before ALL of the participant's
CAUTION
benefit is paid to the participant or beneficiary,
information on the participant's remaining benefit shall be
filed on the Form 8955-SSA filed for the plan year
following the last plan year within which the payment
ceased.

In general, for a plan to which only one employer
contributes, a participant must be reported on Form
8955-SSA if:
1. The participant separates from service covered by
the plan in a plan year, and
2. The participant is entitled to a deferred vested
benefit under the plan.

!

Transfer of a Participant's Benefit to
the Plan of a New Employer

In general, information on the deferred vested
retirement benefit of a plan participant must be filed no
later than on the Form 8955-SSA filed for the plan year
following the plan year in which the participant separates
from service covered by the plan. However, you can
report a deferred vested participant on the Form
8955-SSA filed for the plan year in which the participant
separates from service under the plan if you want to report
earlier. Do not report a participant more than once unless
you are revising or updating information on a prior Form
8955-SSA or Schedule SSA (Form 5500). See the
Specific Instructions for Part III, line 9, codes B, C, or D.

When the benefit of a separated participant with deferred
vested benefits is transferred from one plan to the plan of
a new employer,
1. The new plan administrator should complete a Form
8955-SSA using:
Entry Code C for Part III, line 9, column (a), when the
original plan information is available, or
Entry Code A for Part III, line 9, column (a), when the
original plan information is not available.
2. The original plan administrator should complete a
Form 8955-SSA using Entry Code D for Part III, line 9,
column (a).

For purposes of determining when to report a
separated participant, a single employer plan is a plan to
which only one employer contributes. A single employer
plan includes a plan maintained by a controlled group of
corporations which are treated as a single employer under
section 414(b), and a plan maintained by trades or
businesses under common control which are treated as a
single employer under section 414(c).

Where To File

Send the completed Form 8955-SSA to:
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201-0024

In general, for a plan to which more than one employer
contributes, a participant must be reported on Form
8955-SSA if:
1. The participant incurs two successive one-year
breaks in service (as defined in the plan for vesting
purposes), and
2. The participant is (or may be) entitled to a deferred
vested benefit under the plan.

Private delivery services (PDSs). In addition to the
United States mail, you can use the private delivery
services designated by the IRS to meet the “timely mailing
as timely filing/paying” rule for tax returns and payments.
These delivery services include only the following.
DHL Express (DHL): DHL Same Day Service.
Federal Express (FedEx): FedEx Priority Overnight,
FedEx Standard Overnight, FedEx 2Day, FedEx
International Priority, and FedEx International First.
United Parcel Service (UPS): UPS Next Day Air, UPS
Next Day Air Saver, UPS 2nd Day Air, UPS 2nd Day Air
A.M., UPS Worldwide Express Plus, and UPS Worldwide
Express.
The private delivery service can tell you how to get
written proof of the mailing date.
Private delivery services should send Form 8955-SSA
to:

For these purposes, a multiemployer plan and a
multiple-employer plan are treated as a plan to which
more than one employer contributes.
In general, information about the deferred vested
retirement benefit of a plan participant must be reported
on the Form 8955-SSA filed for the plan year in which the
participant completes the second of two consecutive
one-year breaks in service. Consecutive one-year breaks
in service are defined in the plan for vesting percentage
purposes. The participant may be reported earlier on the
Form 8955-SSA filed for the plan year in which the
participant completed the first one-year break in service.

Internal Revenue Service
1973 Rulon White Blvd.
Ogden, UT 84404

When Not To Report a Participant

A participant who has not been previously reported is not
required to be reported on Form 8955-SSA if, before the
date the Form 8955-SSA is required to be filed (including
any extension of time for filing), the participant:
-3-

How To File

Use only whole dollars. Round off cents to whole
dollars. Drop any amount less than 50 cents and increase
any amount from 50 to 99 cents to the next higher dollar.

Follow the line-by-line instructions to complete the Form
8955-SSA. Answer all questions about the plan, unless
otherwise specified.

Penalties

The Internal Revenue Code imposes a penalty for failure
to file a registration statement (including failure to include
all required participants). The penalty is $1 for each
participant not reported and for each day multiplied by the
number of days the failure continues. The penalty, up to a
maximum of $5,000, is imposed on the person failing to so
file unless it is shown the failure is due to reasonable
cause.

The Form 8955-SSA must be filed with the IRS.
The Form 8955-SSA and any attachments with
CAUTION
the form are NOT open to public inspection. DO
NOT attach a Form 8955-SSA (or a previous year's
Schedule SSA (Form 5500)) to a Form 5500 or Form
5500-SF required to be filed with the Department of Labor
(DOL) filing system (“EFAST2”). Because of privacy
concerns, the inclusion of a social security number on the
Form 5500, Form 5500-SF, or on a schedule or
attachment that is filed with the DOL using EFAST2, may
result in the return of the filing.

!

In the case of a failure to file a notification of a change
in the status of the plan (such as a change in the plan
name or a termination of the plan), or a change in the
name or address of the plan administrator, the Code
imposes a penalty of $1 for each day during which such
failure occurs. The penalty, up to a maximum of $1,000, is
imposed on the person failing to so file unless it is shown
the failure is due to reasonable cause.

Electronic and paper filing. You can:
Use SSA-approved software to complete and
electronically file a Form 8955-SSA. For more information,
go to IRS.gov, search for and select “Form 8955-SSA
Resources” and then select “Approved Software Vendors
Form 8955-SSA”.
Use a personal computer to complete the online fillable
Form 8955-SSA on the IRS website at
www.irs.gov/formspubs before printing, signing, and
mailing it to the IRS. A barcode capturing the data you
entered on the form will appear on the completed pages
when printed. A form partially completed online and
partially completed (other than the signature) on printed
paper will cause processing delays and may result in
correspondence.
Use a printed Form 8955-SSA ordered from the IRS by
calling 1-800-TAX-FORM (1-800-829-3676). When
completing the form, use as many pages 2 of the Form
8955-SSA as necessary and number them in sequential
order.

The Code requires that each plan administrator
required to file a registration statement must, before the
expiration of the time prescribed for the filing of the form,
also furnish to each affected participant an individual
statement setting forth the information required to be
contained in the form. A penalty of $50 is imposed on the
person required to furnish the statement to each affected
participant for each willful failure to furnish the statement
or a willful furnishing of a false statement.

Specific Instructions
PART I

Enter the calendar or fiscal year beginning and ending
dates of the plan year (not to exceed 12 months in length)
for which you are reporting information. Express the dates
in numerical month, day, and year in the following order
(“MMDDYYYY”).

Note. Remember to use additional pages 2 of the 2013
Form 8955-SSA only if additional pages are needed to
add separated participants. Do not use nonstandard
pages 2.

For a plan year of less than 12 months (short plan
year), insert the short plan year beginning and ending
dates on the line provided at the top of the form. For
purposes of this form, the short plan year ends on the date
of the change in accounting period or the complete
distribution of the plan's assets.

Processing tips. To reduce the possibility of
correspondence and penalties:
Sign and date the Form 8955-SSA.
Check your information to avoid errors.
Complete all applicable lines on the form unless
otherwise specified.
All information should be printed in the specific fields
provided on the form.
Do not mark on or near any barcode.
Paper should be clean without glue or other sticky
substances.
Do not staple the form pages. Use binder clips or other
fasteners that do not perforate the paper.
Do not submit extraneous material or information, such
as arrows used to indicate where to sign, notes between
preparers of the report, or notations on the form.
File the Form 8955-SSA using the address specified in
the instructions under Where To File.

Line A. Check this box if you are electing to file this form
voluntarily. The plan administrators of plans, such as
governmental plans and non-electing church plans, not
subject to the vesting standards of section 203 of ERISA
are not required to file this form but may elect to do so. If
such a plan administrator so elects, the plan administrator
is encouraged to provide as much information as
possible, but no specific requirements are imposed.
Note. Only the plan administrators of plans subject to the
vesting standards of section 203 of ERISA must file the
Form 8955-SSA.
Line B. Check this box if this Form 8955-SSA amends a
previously filed Schedule SSA (Form 5500) or Form
8955-SSA.
-4-

If the plan sponsor is a group of individuals, get a single
EIN for the group (providing the group name).

Line C. Check the appropriate box if an extension of time
has been filed using Form 5558, or if an automatic or
special extension has been granted. If a special extension
has been granted, enter the description of the special
extension exactly as it is listed in the announcement. See
Other Extensions of Time To File for additional information
regarding special extensions.

Line 2c. Enter the plan sponsor's trade name if that trade
name is different from the plan sponsor's name entered
on line 2a.
Line 2e. If you want a third party to receive mail for the
plan, enter “C/O” followed by the third party's name and
complete the applicable mailing address in lines 2f
through 2l.

PART II

Please verify that the employer identification number (EIN)
and plan number (PN) being used on this Form 8955-SSA
are correct for this plan.

Line 2f. Enter the sponsor's street address. A post office
box may be entered if the Post Office does not deliver
mail to the sponsor's street address.

Line 1a. Enter the formal name of the plan or enough
information to identify the plan. Abbreviate if necessary.

Line 2g. Enter the name of the city.

Line 1b. Enter the three-digit number that the employer
or plan administrator assigned to the plan and uses to file
the plan's Form 5500 series return/report.

Line 2h. Enter the two-character abbreviation for the U.S.
state or possession.
Line 2j. Enter the foreign province or state, if applicable.

Line 2a. Enter the name of the plan sponsor. The term
“plan sponsor” means:
the employer, for a plan that a single employer
established or maintains;
the employee organization in the case of a plan of an
employee organization; or
the association, committee, joint board of trustees, or
other similar group or representatives of the parties who
established or maintain the plan (in the case of a plan
established or maintained jointly by one or more
employers and one or more employee organizations, or
by two or more employers).

Line 2k. Enter the foreign country, if applicable.
Line 2l. Enter the foreign postal code, if applicable.
Leave the U.S. state and ZIP code blank if completing
line 2k or line 2l.
Line 3a. Enter the plan administrator's name. Enter
“Same” if the plan administrator identified on line 3a is the
same as the plan sponsor identified on line 2a and leave
lines 3b through 3k blank.
Plan administrator for this purpose means:
The person or group of persons specified as the
administrator by the instrument under which the plan is
operated,
The plan sponsor/employer if an administrator is not so
designated, or
Any other person prescribed by regulations if an
administrator is not designated and a plan sponsor cannot
be identified.

Note. In the case of a multiple-employer plan, if an
association or similar entity is not the sponsor, enter the
name of a participating employer as sponsor. The plan
administrator of a plan maintained by a controlled group of
corporations should enter the name of the member of the
controlled group that is entered on the Form 5500 series
return/report as the plan sponsor. The same name must
be used in all subsequent filings of the Form 8955-SSA for
the multiple-employer plan or controlled group (see
instructions for line 5 about changes in sponsorship).

Note. Employees of the plan sponsor who perform
administrative functions for the plan are generally not the
plan administrator unless specifically designated in the
plan document. If an employee of the plan sponsor is
designated as the plan administrator, that employee must
obtain an EIN.

Line 2b. Enter the sponsor's nine-digit EIN. Do not use a
social security number (SSN). Sponsors without an EIN
must apply for one as soon as possible.
EINs are issued by the IRS. To apply for an EIN:
Mail or fax Form SS-4, Application for Employer
Identification Number, obtained by calling
1-800-TAX-FORM (1-800-829-3676) or at the IRS website
at IRS.gov.
Call 1-800-829-4933 to receive your EIN by telephone.
Select the Online EIN Application link at IRS.gov. The
EIN is issued immediately once the application
information is validated. (The online application process is
not yet available for corporations with addresses in foreign
countries.)
A multiple-employer plan or plan of a controlled group
of corporations should use the EIN of the sponsor
identified in line 2a. The EIN must be used in all
subsequent filings of the Form 8955-SSA. (See
instructions for line 5 about changes in EIN.)

Line 3b. Enter the plan administrator's nine-digit EIN.
Plan administrators who do not have an EIN, must apply
for one as described in the instructions for line 2b.
Line 3c. If you want a third party to receive mail for the
plan administrator, enter “C/O” followed by the third
party's name and complete the applicable mailing address
in lines 3e through 3k.
Line 3e. Enter the plan administrator's street address. A
post office box may be entered if the Post Office does not
deliver mail to the sponsor's street address.
Line 3f. Enter the name of the city.
Line 3g. Enter the two-character abbreviation for the U.S.
state or possession.
Line 3i. Enter the foreign province or state, if applicable.
Line 3j. Enter the foreign country, if applicable.
-5-

Line 3k. Enter the foreign postal code, if applicable.
Leave the U.S. state and ZIP code blank if completing
line 3j or line 3k.

on the form. If more than one page 2 of the form is filed for
one plan, only one page 1 of the Form 8955-SSA should
be signed and filed with the pages 2 for the plan.

Line 4. If the plan administrator's name and/or EIN have
changed since the most recent Schedule SSA (Form
5500) or Form 8955-SSA was filed for this plan, enter the
plan administrator's name and EIN as they appeared on
the most recently filed Schedule SSA (Form 5500) or
Form 8955-SSA.

PART III

Enter the name of the plan, the plan number, and the plan
sponsor's EIN at the top of each page 2.
Line 9, column (a). Enter the appropriate code from the
following list:
Code Use this code for a participant not previously
A
reported. Also complete columns (b) through
(g).
Code Use this code for a participant previously
B
reported under the plan number shown on this
form to modify some of the previously reported
information. Enter all the current information for
columns (b) through (g). You do not need to
report a change in the value of a participant's
account since that is likely to change. However,
you may report such a change if you want.
Code Use this code for a participant previously
C
reported under the plan of a different plan
sponsor and who will now be receiving a future
benefit from the plan reported on this form. Also
complete columns (b), (c), (h), and (i).
Code Use this code for a participant previously
D
reported under the plan number shown on this
form who is no longer entitled to those deferred
vested benefits. This includes a participant who
has begun receiving benefits, has received a
lump-sum payout, or has been transferred to
another plan (for example, in the case of a plan
termination). Also complete columns (b) and
(c). Participants should not be reported under
Code D merely because they return to the
service of the plan sponsor.

Failure to indicate on line 4 that a plan
administrator was previously identified by a
CAUTION
different name or EIN could result in
correspondence from the IRS.

!

Line 5. If the plan sponsor's name and/or EIN have
changed since the most recently filed Schedule SSA
(Form 5500) or Form 8955-SSA for this plan, enter the
plan sponsor's name, EIN, and the three-digit plan
number as they appeared on the most recently filed
Schedule SSA (Form 5500) or Form 8955-SSA.

!

CAUTION

Failure to indicate on line 5 that a plan sponsor
was previously identified by a different name or
EIN could result in correspondence from the IRS.

Line 6a. For a plan to which only one employer
contributes, provide the total number of participants
entitled to a deferred vested benefit who separated from
service in the 2012 plan year and who were not previously
reported. For a plan to which more than one employer
contributes, provide the total number of participants
entitled to a deferred vested benefit who completed the
second of two consecutive one-year breaks in service in
the 2013 plan year and who were not previously reported.
Line 6b. For a plan to which only one employer
contributes, provide the total number of participants
entitled to a deferred vested benefit who separated from
service under the plan in the 2013 plan year and who are
reported in Part III of this form. For a plan to which more
than one employer contributes, provide the total number
of participants entitled to a deferred vested benefit who
separated from service under the plan in 2013 or who
completed the first one-year break in service in the 2013
plan year, and who are reported in Part III of this form. See
When To Report a Separated Participant.

Line 9, column (b). Enter the exact SSN of each
participant listed. If the participant is a foreign national
employed outside the United States who does not have
an SSN, enter the word “FOREIGN.”
Line 9, column (c). Enter each participant's name
exactly as it appears on the participant's social security
card. Do not enter periods; however, initials, if on the
social security card, are permitted.
After the last name column, there is a check mark
column. Check the box for each participant whose
information is based on incomplete records. Information
for a participant may be based on incomplete records
where more than one employer contributes to the plan
and the records at the end of the plan year are incomplete
regarding the participant's service. Check the box next to
a participant's name if:
1. The amount of the participant's vested benefit is
based on records which are incomplete as to the
participant's covered service (or other relevant service) or
2. The plan administrator is unable to determine from
the records of the participant's service if the participant is
vested in any deferred retirement benefit but there is a

Do not include any participants on line 6a or 6b
who were previously reported on a Form
CAUTION
8955-SSA or a Schedule SSA (Form 5500).
Accordingly, only those participants who are listed with an
Entry Code A on page 2 should be included on line 6a or
6b.

!

Line 7. The sum of lines 6a and 6b should equal the
number on line 7.
Line 8. Check the appropriate box as to whether the plan
administrator provided the individual statement to each
participant required to receive one. See Penalties.
Signature. The Form 8955-SSA must be signed and
dated by the plan sponsor and by the plan administrator. If
the plan administrator and the plan sponsor are the same
person, include only the signature as plan administrator
-6-

significant likelihood that the participant is vested in such
a benefit. See Regulations section 1.6057-1(b)(3).

C Semiannually
D Quarterly
E Monthly
M Other

Line 9, column (d). From the following list, select the
code that describes the type of annuity that will be
provided for the participant. Enter the code that describes
the type of annuity that normally accrues under the plan at
the time of the participant's separation from service
covered by the plan (or, for a plan to which more than one
employer contributes, at the time the participant incurs the
second consecutive one-year break in service under the
plan).

Line 9, column (f). For a defined benefit plan, enter the
amount (in whole dollars) of the periodic payment that a
participant is entitled to receive.
In general, a deferred vested benefit under a defined
benefit plan would be reported under line 9(f) as the
periodic payment that the participant is entitled to receive.
The plan administrator may, however, report a different
form of benefit if the plan administrator considers it more
appropriate. The plan administrator of a cash balance
plan may report a participant's benefit as the participant's
hypothetical account balance. In that case, the plan
administrator may enter Code A (a single sum) in column
9(d) and Code A (a lump sum) in column 9(e).
For a multiemployer plan, if the amount of the periodic
payment cannot be accurately determined because the
plan administrator does not maintain complete records of
covered service, enter an estimated amount.

Type of Annuity Code
A A single sum
B Annuity payable over fixed number of years
C Life annuity
D Life annuity with period certain
E Cash refund life annuity
F Modified cash refund life annuity
G Joint and last survivor life annuity
M Other
Line 9, column (e). From the following list, select the
code that describes the benefit payment frequency during
a 12-month period.

Line 9, column (g). For defined contribution plans, enter
the value (in whole dollars) of the participant's account.
Line 9, columns (h) and (i). Show the EIN and plan
number of the plan under which the participant was
previously reported.

Type of Payment Code
A Lump sum
B Annually

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal
Revenue laws. Sections 6057 and 6109 require you to provide the information requested on this form. We need it to
determine whether the plan properly accounts for the deferred vested retirement benefits of separated participants.
Failure to provide this information, or providing false or fraudulent information, may subject you to penalties.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books and records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of the Internal Revenue Code. Generally,
tax returns and return information are confidential, as required by section 6103.
However, section 6103 authorizes disclosure of the information to others. Pursuant to section 6057(d), we will
disclose this information to the Social Security Administration for use in administering the Social Security Act. This
information may also be disclosed to the Department of Justice for civil or criminal litigation, to the Department of Labor
or the Pension Benefit Guarantee Corporation for use in administering ERISA, and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. It may also be disclosed to
other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated
average time is 49 minutes.
If you have suggestions for making this form simpler, we would be happy to hear from you. You can send us
comments from www.irs.gov/formspubs. Click on “More Information” and then on “Comment on Tax Forms and
Publications.” You can also send your comments to the Internal Revenue Service, Tax Forms and Publications Division,
1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to this address. Instead, see Where
To File, earlier.

-7-