| Guidance |
Name of Plan as shown on Form 5500 |
(no dashes or spaces) |
|
Plan Sponsor Employer Identification Number (EIN) (no dashes or spaces) |
(no dashes or spaces) |
|
Plan Administrator Employer Identification Number (EIN) (no dashes or spaces) |
(if applicable) |
Plan Administrator phone number (no dashes or spaces) |
Street Address (room, apt., suite no. and street, or P.O. box) |
City of Plan Administrator identified in column G |
State (XX) of Plan Administrator identified in column G |
Zip (XXXXX) of Plan Administrator identified in column G |
Foreign Province/State (if applicable) of Plan Administrator identified in column G |
Foreign Country (if applicable) of Plan Administrator identified in column G |
Foreign Postal Code (if applicable) of Plan Administrator (no dashes or spaces) identified in column G |
Enter the social security number (or ITIN if applicable) (no dashes or spaces) of each participant who (1) is a separated vested participant (as described in 26 U.S.C. 6057(a)(2)(C)(i) and (ii)), (2) is owed a benefit, and (3) has reached age 65 (or older). |
First Name of Participant |
Middle Name of Participant |
Last Name of Participant |