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Department of the Treasury
Internal Revenue Service
2023

Instructions for Form

8955-SSA

Annual Registration Statement Identifying Separated
Participants With Deferred Vested Benefits

Section references are to the Internal Revenue Code, unless A Form 8955-SSA need not be filed for a year if no
otherwise noted. ERISA refers to the Employee Retirement information is required to be provided for that year by these
Income Security Act of 1974. instructions.
Future developments. For the latest information about Form 8955-SSA may be filed electronically through the
developments related to Form 8955-SSA and its instructions, FIRE system or on paper. The IRS and the SSA encourage
such as legislation enacted after they were published, go to all filers to file Form 8955-SSA electronically. Filing
IRS.gov/Form8955SSA. electronically saves time and effort and helps ensure
accuracy. Certain filers, however, are required to file the 2023
Purpose of Form Form 8955-SSA electronically. For more information, see
How To File.
Form 8955-SSA, the designated successor to Schedule SSA
(Form 5500), is used to satisfy the reporting requirements of Reporting requirement. Under section 6057(b), plan
section 6057(a). Form 8955-SSA is a stand-alone reporting administrators must notify the Secretary of the Treasury of
form filed with the IRS. See Where To File. DO NOT file certain changes to the plan and the plan administrator. These
Form 8955-SSA with Form 5500, Annual Return/Report of changes are reported on the plan’s Form 5500 return/report.
Employee Benefit Plan, or Form 5500-SF, Short Form Plan administrators should report these changes on the Form
Annual Return/Report of Small Employee Benefit Plan. 5500 return/report for the plan year in which the change
occurs as indicated in the Form 5500 instructions.
Use Form 8955-SSA to report information relating to each
participant who separated from service covered by the plan Telephone Assistance
and is entitled to a deferred vested benefit under the plan but If you have questions and need assistance completing this
is not paid this retirement benefit. The plan administrator of form, call the IRS Help Line at 877-829-5500 and follow the
each plan subject to the vesting requirements must file Form directions as prompted. This toll-free telephone service is
8955-SSA for participants who have a deferred vested available Monday through Friday.
benefit under the plan and:
• Separated from service covered by the plan, but vested How To Get Forms and Publications
retirement benefits are not paid and were not previously
reported (using Entry Code A in Part III, line 9, column (a)); Internet. You can access the IRS website 24 hours a day, 7
• Were previously reported under the plan but whose days a week at IRS.gov to:
information is being corrected (using Entry Code B in Part III, • Download forms, instructions, and publications;
line 9, column (a)); • Order IRS products online;
• Were previously reported as deferred vested participants • Research your tax questions online;
on another plan's filing if their benefits were transferred (other • Search publications online by topic or keyword; and
than in a rollover) to the plan of a new employer during the • Sign up to receive local and national tax news by email.
covered period (using Entry Code C in Part III, line 9, column You can find forms, instructions, and publications by
(a)); or visiting the IRS website at IRS.gov/FormsPubs or IRS.gov/
• Were previously reported under the plan but have been OrderForms.
paid out or are no longer entitled to those deferred vested
benefits (using Entry Code D in Part III, line 9, column (a)). Photographs of Missing Children
For more information on required participant information, The Internal Revenue Service is a proud partner with the
see the instructions for Part III. National Center for Missing & Exploited Children® (NCMEC).
Photographs of missing children selected by the Center may
The information reported on Forms 8955-SSA is generally appear in instructions on pages that would otherwise be
given to the Social Security Administration (SSA). The SSA blank. You can help bring these children home by looking at
provides the reported information to separated participants the photographs and calling 1-800-THE-LOST
when they file for social security benefits. (1-800-843-5678) if you recognize a child.
Note. The SSA no longer processes nonstandard pages 2.
Report information about separated participants only on General Instructions
page 2 of Form 8955-SSA. If additional space is needed for
separated participants, use additional pages 2 only. Do not Who Must File
add another page 1 of Form 8955-SSA, spreadsheets, or Plan administrators of plans subject to the vesting standards
other nonstandard formats. 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

Dec 29, 2023 Cat. No. 52730V

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must file a Form 8955-SSA for the plan's deferred vested Using Extension of Time To File Federal Income
participants. A plan administrator is not required to report a Tax Return
separated participant if the participant's deferred vested
benefits are attributable to an annuity contract or custodial An automatic extension of time to file Form 8955-SSA until
account that is not required to be treated as part of the the due date of the federal income tax return of the employer
section 403(b) plan assets for purposes of the reporting will be granted if all of the following conditions are met.
requirements of ERISA Title I, as set forth in the Department 1. The plan year and the employer's tax year are the
of Labor (DOL) Field Assistance Bulletin (FAB) 2009-02. For same.
this exception to apply: 2. The employer has been granted an extension of time
1. The contract or account would have to have been to file its federal income tax return after the normal due date
issued to a current or former employee before January 1, for filing the Form 8955-SSA.
2009; 3. A copy of the application for extension of time to file
2. The employer would have to have ceased having any the federal income tax return is retained with the plan's
obligation to make contributions (including employee salary records.
reduction contributions), and in fact ceased making
contributions to the contract or account before January 1, Note. A tax-exempt organization filing Form 8868,
2009; Application for Automatic Extension of Time To File an
Exempt Organization Return or Excise Taxes Related to
3. All the rights and benefits under the contract or Employee Benefit Plans, to request an extension of time to
account would have to be legally enforceable against the file a Form 990 series return is automatically granted an
issuer or custodian by the participant without any involvement extension of time to file Form 8955-SSA until the extended
by the employer; and due date of filing their Form 990 series return if all conditions
4. The participant would have to be fully vested in the listed above are met.
contract or account.
Be sure to check the “automatic extension” box on Part I,
For more information, please see DOL FAB 2009-02 at line C, at the top of the form. An extension of time granted by
www.dol.gov. using this automatic extension procedure CANNOT be
Sponsors and administrators of government, church, and extended further by filing a Form 5558. It also cannot be
other plans that are not subject to the vesting standards of extended more than 9 / months beyond the close of the plan 1 2
section 203 of ERISA (including plans that cover only owners year.
and their spouses or cover only partners and their spouses)
may elect to file Form 8955-SSA voluntarily. See the Other Extensions of Time To File
instructions for Part I, line A. The IRS may from time to time announce special extensions
of time under certain circumstances, such as extensions for
Note. If the 2023 Form 5500 is the final return/report of the presidentially declared disasters or for service in, or in
plan, the Form 8955-SSA filed for the 2023 plan year must support of, the Armed Forces of the United States in a
report information on deferred vested participants, including combat zone. See IRS.gov for announcements of special
reporting that previously reported deferred vested extensions. If you are relying on a special extension, check
participants are no longer deferred vested participants. the box on line C and enter the exact language describing the
announcement in the space provided. For example, indicate
When To File “Disaster Relief Extension” or “Combat Zone Extension.”
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 Amended Registration Statement
the last day of that plan year (plus extensions). This due date File a 2023 Form 8955-SSA to correct errors and/or
may be extended under some circumstances. See Extension omissions in a previously filed statement. Check the box for
of Time To File below. Part I, line B (“amended registration statement”). The
If the filing due date falls on a Saturday, Sunday, or legal amended Form 8955-SSA must conform to the requirements
holiday, Form 8955-SSA may be filed on the next day that is in the How To File section.
not a Saturday, Sunday, or legal holiday. A full and complete Form 8955-SSA must be filed to
correct any such errors and/or omissions. For example, a full
Extension of Time To File and complete Form 8955-SSA must be filed if the plan
administrator determines that incorrect information was
Using Form 5558 provided for a single plan participant.
If filing Form 8955-SSA under an extension of time based on It is important to use a 2023 Form 8955-SSA to report
the filing of Form 5558, Application for Extension of Time To revisions to a participant's information previously filed on a
File Certain Employee Plan Returns, check the “Form 5558” Form 8955-SSA or a Schedule SSA (Form 5500). Because
box on Form 8955-SSA, Part I, line C. A one-time extension the SSA provides information that it has on file to individuals
of time (up to 2 / months) to file Form 8955-SSA may be 1 2 who file for benefits, if this information is not up to date, the
obtained by filing Form 5558 on or before the normal due individual may contact the plan administrator to resolve the
date (not including any extensions) of Form 8955-SSA. difference.
You can paper file Form 5558 with the IRS. File paper
Form 5558 with the Department of the Treasury, Internal Prior Year Statement
Revenue Service Center, Ogden, UT 84201-0045. Because Although Schedule SSA (Form 5500) was previously used to
approved copies of Form 5558 will not be returned to the filer, satisfy the reporting requirements of section 6057(a) for plan
you must retain a copy of the Form 5558 that is filed. See the years prior to January 1, 2009, the Schedule SSA (Form
instructions for Form 5558. 5500) should no longer be filed under any circumstances.

2 Instructions for Form 8955-SSA (2023)

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(See Announcement 2011-21, 2011-12 I.R.B. 567.) Instead,
When Not To Report a Participant
Form 8955-SSA should be filed for all plan years, including
delinquent returns for plan years before 2009. If a paper 2023 A participant who has not been previously reported is not
Form 8955-SSA is used to satisfy filing obligations for plan required to be reported on Form 8955-SSA if, before the date
years before 2009, complete Part I plan year beginning and the Form 8955-SSA is required to be filed (including any
plan year ending dates for the appropriate plan year filed. extension of time to file), the participant:
Forms 8955-SSA for prior years should be sent to the same 1. Is paid some or all of the deferred vested retirement
address as the 2023 Form 8955-SSA. See Where To File benefit (see the Caution),
below. 2. Returns to service covered by the plan and/or accrues
additional retirement benefits under the plan, or
When To Report a Separated
3. Forfeits all the deferred vested retirement benefit.
Participant
If payment of the deferred vested retirement benefit
In general, for a plan to which only one employer contributes, ! ceases before ALL of the participant's vested benefit
a participant must be reported on Form 8955-SSA if: CAUTION is paid to the participant or beneficiary, information on
1. The participant separates from service covered by the the participant's remaining benefit shall be filed on the Form
plan in a plan year, and 8955-SSA filed for the plan year following the last plan year
2. The participant is entitled to a deferred vested benefit within which the payment ceased.
under the plan.
In general, information on the deferred vested retirement Transfer of a Participant's Benefit to
benefit of a plan participant must be filed no later than on the the Plan of a New Employer
Form 8955-SSA filed for the plan year following the plan year When the benefit of a separated participant with deferred
in which the participant separates from service covered by vested benefits is transferred from one plan to the plan of a
the plan. However, you can report a deferred vested new employer:
participant on the Form 8955-SSA filed for the plan year in
which the participant separates from service under the plan if 1. The new plan administrator must complete a Form
you want to report earlier. Do not report a participant more 8955-SSA using Entry Code C for Part III, line 9, column (a),
than once unless you are revising or updating information on and specifying the previous sponsor’s EIN in column (h) and
a prior Form 8955-SSA or Schedule SSA (Form 5500). See the previous plan number in column (i) to complete the
the Specific Instructions for Part III, line 9, code B, C, or D. transfer to the plan.
Note. In the rare case that the previous plan sponsor’s EIN
The determination of whether more than one employer and previous plan number are not available, the new plan
contributes to a plan is based on the number of employers administrator should complete a Form 8955-SSA using Entry
required to contribute to the plan. A plan to which only one Code A for Part III, line 9, column (a).
employer contributes includes a plan maintained by:
• A controlled group of corporations that are treated as a 2. The previous plan administrator must complete a Form
single employer under section 414(b), 8955-SSA using Entry Code D for Part III, line 9, column (a),
• Trades or businesses under common control that are to remove the information previously reported under the plan
treated as a single employer under section 414(c), and for deferred vested participants.
• An affiliated service group that is treated as a single
employer under section 414(m). Where To File
If Form 8955-SSA is sent by United States mail, send the
In general, for a plan to which more than one employer complete form to:
contributes, a participant must be reported on Form
8955-SSA if: Department of the Treasury
1. The participant incurs two successive 1-year breaks in Internal Revenue Service Center
service (as defined in the plan for vesting purposes), and Ogden, UT 84201-0024
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
For these purposes, a multiemployer plan described in designated by the IRS to meet the “timely mailing as timely
section 414(f), a collectively bargained plan described in filing/paying” rule for tax returns and payments. Go to
section 413(a), a multiple-employer plan described in section IRS.gov/PDS for the current list of designated services.
413(c) (including plans described in section 413(e)), and a
multiple-employer plan described in section 403(b)(15) are The PDS can tell you how to get written proof of the
each treated as a plan to which more than one employer mailing date.
contributes. Private delivery services must send Form 8955-SSA to:
In general, information about the deferred vested Internal Revenue Submission Processing Center
retirement benefit of a plan participant must be reported on 1973 Rulon White Blvd.
the Form 8955-SSA filed for the plan year in which the Ogden, UT 84201
participant completes the second of two consecutive 1-year
breaks in service. Consecutive 1-year breaks in service are
defined in the plan for purposes of determining a participant’s How To File
vesting percentage. The participant may be reported earlier Follow the line-by-line instructions to complete Form
on the Form 8955-SSA filed for the plan year in which the 8955-SSA. Answer all questions about the plan, unless
participant completed the first 1-year break in service. otherwise specified.

Instructions for Form 8955-SSA (2023) 3

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Form 8955-SSA must be filed with the IRS. Form Note. Remember to use additional pages 2 of the 2023
! 8955-SSA is NOT open to public inspection. DO Form 8955-SSA only if additional pages are needed to add
CAUTION NOT attach a Form 8955-SSA (or a previous year's separated participants. Do not use nonstandard pages 2.
Schedule SSA (Form 5500)) to a Form 5500 or Form
Processing tips. To reduce the possibility of
5500-SF required to be filed with the Department of Labor
correspondence and penalties:
(DOL) filing system (“EFAST2”).
• Sign and date Form 8955-SSA.
Mandatory electronic filing. For 2013 and prior years, • Check your information to avoid errors.
filers had the option of filing Form 8955-SSA electronically. • Complete all applicable lines on the form unless otherwise
Beginning with the 2014 Form 8955-SSA, however, some specified.
filers are now required to file the form electronically. A filer • Print all information necessary in the specific fields
must electronically file the 2023 Form 8955-SSA if the filer is provided on the form.
required to file 250 returns of any type during the calendar • Do not mark on or near any barcode.
year that includes the first day of the plan year. “Returns” for • Do not use glue or other sticky substances on the paper
this purpose include information returns (for example, Forms form.
W-2 and 1099), income tax returns, employment tax returns • Do not staple the form pages. Use binder clips or other
(including quarterly Forms 941), and excise tax returns. If a fasteners that do not perforate the paper.
filer is required to file a Form 8955-SSA electronically but • Do not submit extraneous material or information, such as
does not, the filer is considered not to have filed the form arrows used to indicate where to sign, notes between
even if a paper return is submitted. preparers of the report, or notations on the form.
• File Form 8955-SSA using the address specified in the
Note. On February 23, 2023, the Department of the Treasury instructions under Where To File, earlier.
published final regulations, Electronic-Filing Requirements for • Use only whole dollars. Round off cents to whole dollars.
Specified Returns and Other Documents, implementing the Drop any amount less than 50 cents and increase any
reduced mandatory electronic filing threshold under section amount from 50 to 99 cents to the next higher dollar.
2301 of the Taxpayer First Act of 2019 (the “TFA”). Under the
final regulations, a filer who is required to file at least 10 Penalties
returns with the IRS during the calendar year must file Form Section 6652(d)(1) imposes a penalty for failure to file a
8955-SSA electronically for plan years beginning on or after registration statement (including failure to include all required
January 1, 2024. The mandatory electronic filing threshold for participants). The penalty is $10 for each participant not
e-filing Form 8955-SSA remains 250 returns for the 2023 reported and for each day multiplied by the number of days
plan year. The instructions will be updated next year for the failure continues. The penalty, up to a maximum of
changes. $50,000, is imposed on the person failing to properly file
unless it is shown the failure is due to reasonable cause.
The requirement to file the 2023 Form 8955-SSA
electronically does not apply to filers filing for relief under In the case of a failure to file a notification of a change in
Notice 2014-35, 2014-23 I.R.B. 1072 (relating to filers who the status of the plan (such as a change in the plan name or a
qualify for relief under the Department of Labor’s Delinquent termination of the plan), or a change in the name or address
Filer Voluntary Compliance Program). See Regulations of the plan administrator, section 6652(d)(2) imposes a
section 301.6057-3 for more information on the mandatory penalty of $10 for each day during which such failure occurs.
electronic filing of Form 8955-SSA. The penalty, up to a maximum of $10,000, is imposed on the
The IRS may waive the requirements to file Form person failing to so file unless it is shown the failure is due to
8955-SSA electronically in cases of undue economic reasonable cause.
hardship. For information on filing a request for a hardship The Code provides that each plan administrator required
waiver, see Rev. Proc. 2015-47, 2015-39 I.R.B. 419, available to file a registration statement must, before the expiration of
at IRS.gov/irb/2015-39_IRB/ar16.html, and IRS.gov/ the time prescribed for the filing of the form, also furnish to
Retirement-Plans/FAQs-Regarding-Form-8955-SSA. each affected participant an individual statement setting forth
Electronic and paper filing. You can: the information required to be contained in the form. Section
• Use SSA-approved software to complete and 6690 imposes a penalty of $50 on the person required to
electronically file a Form 8955-SSA. For more information, go furnish the individual statement to each affected participant
to IRS.gov, search for and select “Form 8955-SSA for each willful failure to furnish the statement or a willful
Resources,” and then select “Approved Software Vendors furnishing of a false statement.
Form 8955-SSA.”
• Use a personal computer to complete the online fillable
Specific Instructions
Form 8955-SSA on the IRS website at IRS.gov/FormsPubs
before printing, signing, and mailing it to the IRS. A barcode PART I
capturing the data you entered on the form will appear on the
completed pages when printed. A form partially completed Enter the calendar or fiscal year beginning and ending dates
online and partially completed (other than the signature) on of the plan year (not to exceed 12 months in length) for which
printed paper will cause processing delays and may result in you are reporting information. Express the dates in numerical
correspondence from the IRS. month, day, and year in the following order: (MMDDYYYY).
• Use a printed Form 8955-SSA ordered from the IRS For a plan year of less than 12 months (short plan year),
website at IRS.gov/OrderForms. When completing the form, enter the short plan year beginning and ending dates on the
use as many pages 2 of the Form 8955-SSA as necessary to line provided at the top of the form. For purposes of this form,
list separated participants and number the pages in the short plan year ends on the date of a change in
sequential order. accounting period or the complete distribution of the plan's
assets.

4 Instructions for Form 8955-SSA (2023)

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Line A. Check this box if you are electing to file this form • By mailing or faxing Form SS-4, Application for Employer
voluntarily. The plan administrators of plans, such as Identification Number.
governmental plans and non-electing church plans, not A multiple-employer plan or plan of a controlled group of
subject to the vesting standards of section 203 of ERISA are corporations should use the EIN of the sponsor identified on
not required to file this form but may elect to do so. If such a line 2a. The EIN must be used in all subsequent filings of
plan administrator so elects, the plan administrator is Form 8955-SSA. (See the instructions for line 5 about
encouraged to provide as much information as possible, but changes in EIN.)
no specific requirements are imposed. If the plan sponsor is a group of individuals, get a single
EIN for the group (providing the group name).
Note. Only the plan administrators of plans subject to the
vesting standards of section 203 of ERISA must file the Form Line 2c. Enter the plan sponsor's trade name if that trade
8955-SSA. name is different from the plan sponsor's name entered on
line 2a.
Line B. Check this box if this Form 8955-SSA amends a
previously filed Schedule SSA (Form 5500) or Form Line 2e. If you want a third party to receive mail for the plan,
8955-SSA. enter “C/O” followed by the third party's name and complete
the applicable mailing address on lines 2f through 2l.
Line C. Check the appropriate box if an extension of time
has been filed using Form 5558, or if an automatic or special Line 2f. Enter the plan sponsor's street address. A post
extension has been granted. If a special extension has been office box may be entered if the Post Office does not deliver
granted, enter the description of the special extension exactly mail to the plan sponsor's street address.
as it is listed in the announcement. See Other Extensions of Line 2g. Enter the name of the city.
Time To File, earlier, for additional information regarding
special extensions. Line 2h. Enter the two-character abbreviation for the U.S.
state or territory.
PART II Line 2j. Enter the foreign province or state, if applicable.
Please verify that the employer identification number (EIN)
and plan number (PN) being used on this Form 8955-SSA Line 2k. Enter the foreign country, if applicable.
are correct for this plan. Line 2l. Enter the foreign postal code, if applicable. Leave
Line 1a. Enter the formal name of the plan or enough the U.S. state and ZIP code blank if completing line 2k or
information to identify the plan. Abbreviate if necessary. line 2l.
Line 1b. Enter the three-digit number that the employer or Line 3a. Enter the plan administrator's name. Enter “Same”
plan administrator assigned to the plan and uses to file the if the plan administrator identified on line 3a is the same as
plan's Form 5500 return/report. the plan sponsor identified on line 2a and leave lines 3b
through 3k blank.
Line 2a. Enter the name of the plan sponsor. The term “plan
“Plan administrator” for this purpose means:
sponsor” means:
• The employer, for a plan that a single employer established • The person or group of persons specified as the
administrator by the instrument under which the plan is
or maintains;
operated,
• The employee organization in the case of a plan of an
employee organization; or • The plan sponsor/employer if an administrator is not so
designated, or
• The association, committee, joint board of trustees, or
other similar group or representatives of the parties who • Any other person prescribed by regulations if an
administrator is not designated and a plan sponsor cannot be
established or maintain the plan (in the case of a plan
identified.
established or maintained jointly by one or more employers
and one or more employee organizations, or by two or more Note. Employees of the plan sponsor who perform
employers). administrative functions for the plan are generally not plan
administrators unless specifically designated in the plan
Note. In the case of a multiple-employer plan, if an
document. If an employee of the plan sponsor is designated
association or similar entity is not the sponsor, enter the
as the plan administrator, that employee must obtain an EIN.
name of a participating employer as sponsor. The plan
administrator of a plan maintained by a controlled group of Line 3b. Enter the plan administrator's nine-digit EIN. Plan
corporations should enter the name of the member of the administrators who do not have an EIN must apply for one as
controlled group that is entered on the Form 5500 return/ described in the instructions for line 2b.
report as the plan sponsor. The same name must be used in
Line 3c. If you want a third party to receive mail for the plan
all subsequent filings of the Form 8955-SSA for the
administrator, enter “C/O” followed by the third party's name
multiple-employer plan or controlled group. (See the
and complete the applicable mailing address on lines 3e
instructions for line 5 about changes in sponsorship.)
through 3k.
Line 2b. Enter the sponsor's nine-digit EIN. Do not use a
Line 3e. Enter the plan administrator's street address. A
social security number (SSN). Sponsors without an EIN must
post office box may be entered if the Post Office does not
apply for one as soon as possible.
deliver mail to the sponsor's street address.
EINs are issued by the IRS. You can apply for an EIN:
• Online — Go to the IRS website at IRS.gov/EIN. The EIN is Line 3f. Enter the name of the city.
issued immediately once the application information is Line 3g. Enter the two-character abbreviation for the U.S.
validated. (The online application process is not yet available state or territory.
for corporations with addresses in foreign countries.)
Line 3i. Enter the foreign province or state, if applicable.

Instructions for Form 8955-SSA (2023) 5

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Line 3j. Enter the foreign country, if applicable. PART III
Line 3k. Enter the foreign postal code, if applicable. Leave Enter the name of the plan, the plan number, and the plan
the U.S. state and ZIP code blank if completing line 3j or sponsor's EIN at the top of each page 2.
line 3k. Line 9, column (a). Enter the appropriate code from the
Line 4. If the plan administrator's name and/or EIN have following list.
changed since the most recent Schedule SSA (Form 5500)
or Form 8955-SSA was filed for this plan, enter the plan Code Use this code for a participant not previously
administrator's name and EIN as they appeared on the most A reported. Also, complete columns (b) through
recently filed Schedule SSA (Form 5500) or Form 8955-SSA. (g), as applicable.
Failure to indicate on line 4 that a plan administrator Code Use this code for a participant previously
! was previously identified by a different name or EIN B reported under the plan number shown on this
CAUTION could result in correspondence from the IRS. form to modify some of the previously reported
information. Enter all the current information for
Line 5. If the plan sponsor's name and/or EIN have changed
since the most recently filed Schedule SSA (Form 5500) or columns (b) through (g), as applicable. You do
Form 8955-SSA for this plan, enter the plan sponsor's name, not need to report a change in the value of a
EIN, and the three-digit plan number as they appeared on the participant's account since that is likely to
most recently filed Schedule SSA (Form 5500) or Form change. However, you may report such a
8955-SSA. change if you want.
Failure to indicate on line 5 that a plan sponsor was Code Use this code for a participant previously
C reported under the plan of a different plan
! previously identified by a different name or EIN could
CAUTION result in correspondence from the IRS. sponsor and who will now be receiving a future
benefit from the plan reported on this form.
Line 6a. For a plan to which only one employer contributes, Also, complete columns (b), (c), (h), and (i).
provide the total number of participants entitled to a deferred
vested benefit who separated from service in the 2022 plan Code Use this code for a participant previously
year and who were not previously reported. For a plan to D reported under the plan number shown on this
which more than one employer contributes, provide the total form who is no longer entitled to those deferred
number of participants entitled to a deferred vested benefit vested benefits. This includes a participant who
who completed the second of two consecutive 1-year breaks has begun receiving benefits, has received a
in service in the 2023 plan year and who were not previously lump-sum payout, or has been transferred to
reported. another plan (for example, in the case of a plan
Line 6b. For a plan to which only one employer contributes, termination). Also, complete columns (b) and
provide the total number of participants entitled to a deferred (c). Participants should not be reported under
vested benefit who separated from service under the plan in Code D merely because they return to the
the 2023 plan year and who are reported in Part III of this service of the plan sponsor.
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 2023 or who completed the first 1-year
break in service in the 2023 plan year and who are reported Line 9, column (b). Enter the full nine-digit SSN of each
in Part III of this form. See When To Report a Separated participant listed. Please do not enter only the last four digits
Participant. of the SSN. If the participant is a foreign national employed
outside the United States who does not have an SSN, enter
Do not include any participants on line 6a or 6b who the word “FOREIGN”.
! were previously reported on a Form 8955-SSA or a Line 9, column (c). Enter each participant's name exactly
CAUTION Schedule SSA (Form 5500). Accordingly, only those
participants who are listed with an Entry Code A on page 2 as it appears on the participant's social security card. Do not
should be included on line 6a or 6b. enter periods; however, initials, if on the social security card,
are permitted.
Line 7. The sum of lines 6a and 6b should equal the number After the last name column, there is a checkmark column.
on line 7. Check the box for each participant whose information is
based on incomplete records. Information for a participant
Line 8. Check the appropriate box as to whether the plan
may be based on incomplete records where more than one
administrator provided the individual statement to each
employer contributes to the plan and the records at the end
participant required to receive one. See Penalties.
of the plan year are incomplete regarding the participant's
Signature. Form 8955-SSA must be signed and dated by service. Check the box next to a participant's name if:
the plan sponsor and by the plan administrator. If the plan 1. The amount of the participant's vested benefit is based
administrator and the plan sponsor are the same person, on records that are incomplete as to the participant's covered
include only the signature as plan administrator on the form. service (or other relevant service), or
If more than one page 2 of the form is filed for one plan, only
one page 1 of Form 8955-SSA should be signed and filed 2. The plan administrator is unable to determine from the
with the pages 2 for the plan. records of the participant's service if the participant is vested
in any deferred retirement benefit but there is a significant

6 Instructions for Form 8955-SSA (2023)

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likelihood that the participant is vested in such a benefit. See Line 9, column (g). For defined contribution plans, enter
Regulations section 1.6057-1(b)(3). the value (in whole dollars) of the participant's account.
Line 9, column (d). From the following list, select the code Line 9, columns (h) and (i). Show the EIN and plan
that describes the type of annuity that will be provided for the number of the plan under which the participant was
participant. Enter the code that describes the type of annuity previously reported.
that normally accrues under the plan at the time of the
participant's separation from service covered by the plan (or, Privacy Act and Paperwork Reduction Act Notice. We
for a plan to which more than one employer contributes, at ask for the information on this form to carry out the Internal
the time the participant incurs the second consecutive 1-year Revenue laws of the United States. Sections 6057 and 6109
break in service under the plan). require you to provide the information requested on this form.
We need it to determine whether the plan properly accounts
Type of Annuity Code for the deferred vested retirement benefits of separated
A A single sum participants. Failure to provide this information, or providing
B Annuity payable over fixed number of years false or fraudulent information, may subject you to penalties.
C Life annuity
D Life annuity with period certain You are not required to provide the information requested
E Cash refund life annuity on a form that is subject to the Paperwork Reduction Act
F Modified cash refund life annuity unless the form displays a valid OMB control number. Books
G Joint and last survivor life annuity or records relating to a form or its instructions must be
M Other retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax
Line 9, column (e). From the following list, select the code returns and return information are confidential, as required by
that describes the benefit payment frequency during a section 6103.
12-month period.
Type of Payment Code However, section 6103 authorizes disclosure of the
information to others. Pursuant to section 6057(d), we will
A Lump sum disclose this information to the Social Security Administration
B Annually for use in administering the Social Security Act. This
C Semiannually information may also be disclosed to the Department of
D Quarterly Justice for civil or criminal litigation, to the Department of
E Monthly Labor or the Pension Benefit Guarantee Corporation for use
M Other in administering ERISA, and to cities, states, the District of
Line 9, column (f). For a defined benefit plan, enter the Columbia, and U.S. commonwealths and territories for use in
amount (in whole dollars) of the periodic payment that a administering their tax laws. It may also be disclosed to other
participant is entitled to receive. countries under a tax treaty, to federal and state agencies to
In general, a deferred vested benefit under a defined enforce federal nontax criminal laws, or to federal law
benefit plan would be reported under line 9, column (f), as the enforcement and intelligence agencies to combat terrorism.
periodic payment that the participant is entitled to receive. The time needed to complete and file this form will vary
The plan administrator may, however, report a different form depending on individual circumstances. The estimated
of benefit if the plan administrator considers it more average time is 49 minutes.
appropriate. For example, the plan administrator of a cash
balance plan may report a participant's benefit as the If you have suggestions for making this form simpler, we
participant's hypothetical account balance. In that case, the would be happy to hear from you. You can send us
plan administrator may enter Code A (a single sum) in comments from IRS.gov/FormComments. Or you can write to
column (d) and Code A (a lump sum) in column (e). the Internal Revenue Service, Tax Forms and Publications
For a multiemployer plan, if the amount of the periodic Division, 1111 Constitution Ave. NW, IR-6526, Washington,
payment cannot be accurately determined because the plan DC 20224. Do not send Form 8955-SSA to this address.
administrator does not maintain complete records of covered Instead, see Where To File, earlier.
service, enter an estimated amount.

Instructions for Form 8955-SSA (2023) 7

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