• 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.

Note. Report required information regarding 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.

          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. top Under section 6057(b) plan administrators must notify the Secretary of the Treasury of 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 Return to top

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 Return to top

Internet. top 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. top 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 Return to top

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 Return to top

Who Must File Return to top

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 with respect to the plan's deferred vested participants. Sponsors and administrators of government, church, and other plans which 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.

Note. If the 2012 Form 5500 annual return/report was the final return/report of the plan, the Form 8955-SSA filed for the 2012 plan year must report information on deferred vested participants, including reporting that previously reported deferred vested participants are no longer deferred vested participants.

When To File Return to top

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.

Extension of Time To File Return to top

Using Form 5558
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 2 1/2 months) may be obtained by filing Form 5558 on or before the normal due date (not including any extensions) of the Form.  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 will not be returned to the filer, you should retain a copy of the Form 5558 that is filed.

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 9 ½ 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."

Amended Registration Statement Return to top

File a 2012 Form 8955-SSA to correct errors and/or omissions in a previously filed statement for the 2012 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.

Prior Year Statement Return to top

When To Report a Separated Participant Return to top

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.

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. For these purposes, a multiemployer plan and a multiple employer plan are treated as a plan to which more than one employer contributes.

When Not To Report a Participant Return to top

A participant 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:

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.

Caution! top If payment of the deferred vested retirement benefit ceases before ALL of the participant's 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.

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

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).

Where To File Return to top

Send the completed Form 8955-SSA to:

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.

How To File Return to top

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

Caution! The Form 8955-SSA must be filed with the IRS. The Form 8955-SSA and previous years' Schedules SSA (Form 5500) and any attachments with the form or schedules 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.

Electronic and paper filing. top 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 as necessary and number them in sequential order.

Note.   Remember to use additional pages 2 of the 2012 Form 8955-SSA only if additional pages are needed to add separated participants.  Do not use nonstandard pages 2.

Processing tips. top 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.
• 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.

Penalties Return to top

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.

Specific Instructions Return to top

Part I Return to top

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").

Line A. top 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. top Check this box if this Form 8955-SSA amends a previously filed Schedule SSA (Form 5500) or Form 8955-SSA.

Line C. top 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.

PART II Return to top

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

Line 1b. top Enter the three-digit plan number that the employer or plan administrator assigned to the plan uses for filing the Form 5500 series.

Line 2a. top 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).

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).

Line 2b. top 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.

• 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.)

Line 2c. top 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. top 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.

Line 2f. top 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 2g. top Enter the name of the city.

Line 2h. top Enter the two-character abbreviation for the U.S. state or possession.

Line 2j. top Enter the foreign province or state, if applicable.

Line 2k. top Enter the foreign country, if applicable.

Line 2l. top Enter the foreign routing code, if applicable. Leave the U.S. state and ZIP code blank if completing line 2k or line 2l.

Line 3a. top 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.

• 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. 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 3b. top 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. top 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. top 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. top Enter the name of the city.

Line 3g. top Enter the two-character abbreviation for the U.S. state or possession.

Line 3i. top Enter the foreign province or state, if applicable.

Line 3j. top Enter the foreign country, if applicable.

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

Line 4. top 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.

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

Line 5. top 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. top 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 2011 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 2012 plan year and who were not previously reported.

Line 6b. top 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 2012 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 2012 or who completed the first one-year break in service in the 2012 plan year, and who are reported in Part III of this form. See When To Report a Separated Participant.

Line 7. top The sum of lines 6a and 6b should equal the number on line 7.

Line 8. top 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 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.

Part IIII Return to top

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). top Enter the appropriate code from the following list:

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

Line 9, column (d). top 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).

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). top From the following list, select the code that describes the benefit payment frequency during a 12-month period.

Line 9, column (f). top For a defined benefit plan, enter the amount (in whole dollars) of the periodic payment that a participant is entitled to receive.

Line 9, column (g). top For defined contribution plans, enter the value (in whole dollars) of the participant's account.

Line 9, columns (h) and (i). top Show the EIN and plan number of the plan under which the participant was previously reported.