PDF document

- 1 -

Userid: CPM Schema: Leadpct: 100% Pt. size: 9.5 Draft Ok to Print
instrx
AH XSL/XML Fileid: … s/i8955ssa/2022/a/xml/cycle01/source (Init. & Date) _______

Page 1 of 7 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Department of the Treasury
Internal Revenue Service
2022

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
Purpose of Form 2022 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
The information reported on Forms 8955-SSA is generally Center may appear in instructions on pages that would
given to the Social Security Administration (SSA). The SSA otherwise be blank. You can help bring these children home
provides the reported information to separated participants by looking at 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

Sep 14, 2022 Cat. No. 52730V

- 2 -

Page 2 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

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, to request an extension of time
3. All the rights and benefits under the contract or to file a Form 990 series return is automatically granted an
account would have to be legally enforceable against the extension of time to file Form 8955-SSA until the extended
issuer or custodian by the participant without any due date of filing their Form 990 series return if all conditions
involvement by the employer; and listed above are met.
4. The participant would have to be fully vested in the
contract or account. Be sure to check the “automatic extension” box on Part I,
line C, at the top of the form. An extension of time granted by
For more information, please see DOL FAB 2009-02 at using this automatic extension procedure CANNOT be
www.dol.gov. extended further by filing a Form 5558. It also cannot be
extended more than 9 / months beyond the close of the plan 1 2
Sponsors and administrators of government, church, and year.
other plans that are not subject to the vesting standards of
section 203 of ERISA (including plans that cover only owners Other Extensions of Time To File
and their spouses or cover only partners and their spouses) The IRS may from time to time announce special extensions
may elect to file Form 8955-SSA voluntarily. See the of time under certain circumstances, such as extensions for
instructions for Part I, line A. presidentially declared disasters or for service in, or in
support of, the Armed Forces of the United States in a
Note. If the 2022 Form 5500 is the final return/report of the
combat zone. See IRS.gov for announcements of special
plan, the Form 8955-SSA filed for the 2022 plan year must
extensions. If you are relying on a special extension, check
report information on deferred vested participants, including
the box on line C and enter the exact language describing the
reporting that previously reported deferred vested
announcement in the space provided. For example, indicate
participants are no longer deferred vested participants.
“Disaster Relief Extension” or “Combat Zone Extension.”
When To File
Amended Registration Statement
In general, if a Form 8955-SSA must be filed for a plan year,
File a 2022 Form 8955-SSA to correct errors and/or
it must be filed by the last day of the seventh month following
omissions in a previously filed statement. Check the box for
the last day of that plan year (plus extensions). This due date
Part I, line B (“amended registration statement”). The
may be extended under some circumstances. See Extension
amended Form 8955-SSA must conform to the requirements
of Time To File below.
in the How To File section.
If the filing due date falls on a Saturday, Sunday, or legal A full and complete Form 8955-SSA must be filed to
holiday, Form 8955-SSA may be filed on the next day that is correct any such errors and/or omissions. For example, a full
not a Saturday, Sunday, or legal holiday. and complete Form 8955-SSA must be filed if the plan
administrator determines that incorrect information was
Extension of Time To File provided for a single plan participant.
Using Form 5558 It is important to use a 2022 Form 8955-SSA to report
revisions to a participant's information previously filed on a
If filing Form 8955-SSA under an extension of time based on Form 8955-SSA or a Schedule SSA (Form 5500). Because
the filing of Form 5558, Application for Extension of Time To the SSA provides information that it has on file to individuals
File Certain Employee Plan Returns, check the appropriate who file for benefits, if this information is not up to date, the
box on Form 8955-SSA, Part I, line C. A one-time extension individual may contact the plan administrator to resolve the
of time to file Form 8955-SSA may be obtained by filing Form difference.
5558 on or before the normal due date (not including any
extensions) of Form 8955-SSA. See the instructions for Form Prior Year Statement
5558. You must file Form 5558 with the Department of the Although Schedule SSA (Form 5500) was previously used to
Treasury, Internal Revenue Service Center, Ogden, UT satisfy the reporting requirements of section 6057(a) for plan
84201-0045. Because approved copies of Form 5558 will not years prior to January 1, 2009, the Schedule SSA (Form
be returned to the filer, you should retain a copy of the Form 5500) should no longer be filed under any circumstances.
5558 that is filed. (See Announcement 2011-21, 2011-12 I.R.B. 567.) Instead,

-2- Instructions for Form 8955-SSA (2022)

- 3 -

Page 3 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Form 8955-SSA should be filed for all plan years, including 1. Is paid some or all of the deferred vested retirement
delinquent returns for plan years before 2009. If a paper 2022 benefit (see the Caution),
Form 8955-SSA is used to satisfy filing obligations for plan 2. Returns to service covered by the plan and/or accrues
years before 2009, complete Part I plan year beginning and additional retirement benefits under the plan, or
plan year ending dates for the appropriate plan year filed.
Forms 8955-SSA for prior years should be sent to the same 3. Forfeits all the deferred vested retirement benefit.
address as the 2022 Form 8955-SSA. See Where To File If payment of the deferred vested retirement benefit
below. ! ceases before ALL of the participant's vested benefit
CAUTION is paid to the participant or beneficiary, information
When To Report a Separated on the participant's remaining benefit shall be filed on the
Participant 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:
Transfer of a Participant's Benefit to
1. The participant separates from service covered by the
plan in a plan year, and the Plan of a New Employer
2. The participant is entitled to a deferred vested benefit When the benefit of a separated participant with deferred
under the plan. vested benefits is transferred from one plan 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 1. The new plan administrator must complete a Form
Form 8955-SSA filed for the plan year following the plan year 8955-SSA using Entry Code C for Part III, line 9, column (a),
in which the participant separates from service covered by and specifying the previous sponsor’s EIN in column (h) and
the plan. However, you can report a deferred vested the previous plan number in column (i) to complete the
participant on the Form 8955-SSA filed for the plan year in transfer to the plan.
which the participant separates from service under the plan if Note. In the rare case that the previous plan sponsor’s EIN
you want to report earlier. Do not report a participant more and previous plan number are not available, the new plan
than once unless you are revising or updating information on administrator should complete a Form 8955-SSA using Entry
a prior Form 8955-SSA or Schedule SSA (Form 5500). See Code A for Part III, line 9, column (a).
the Specific Instructions for Part III, line 9, codes B, C, or D. 2. The previous plan administrator must complete a Form
For purposes of determining when to report a separated 8955-SSA using Entry Code D for Part III, line 9, column (a),
participant, a single employer plan is a plan to which only one to remove the information previously reported under the plan
employer contributes. A single employer plan includes a plan for deferred vested participants.
maintained by:
• A controlled group of corporations that are treated as a Where To File
single employer under section 414(b), If Form 8955-SSA is sent by United States mail, send the
• Trades or businesses under common control that are complete form to:
treated as a single employer under section 414(c), and
• An affiliated service group that is treated as a single Department of the Treasury
employer under section 414(m). Internal Revenue Service Center
In general, for a plan to which more than one employer Ogden, UT 84201-0024
contributes, a participant must be reported on Form
8955-SSA if: Private delivery services (PDSs). In addition to the United
1. The participant incurs two successive 1-year breaks in States mail, you can use the private delivery services
service (as defined in the plan for vesting purposes), and designated by the IRS to meet the “timely mailing as timely
2. The participant is (or may be) entitled to a deferred filing/paying” rule for tax returns and payments. Go to
vested benefit under the plan. IRS.gov/PDS for the current list of designated services.
The PDS can tell you how to get written proof of the
For these purposes, a multiemployer plan and a mailing date.
multiple-employer plan are each treated as a plan to which
more than one employer 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.

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:

Instructions for Form 8955-SSA (2022) -3-

- 4 -

Page 4 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Form 8955-SSA must be filed with the IRS. Form • Check your information to avoid errors.
! 8955-SSA is NOT open to public inspection. DO • Complete all applicable lines on the form unless otherwise
CAUTION NOT attach a Form 8955-SSA (or a previous year's specified.
Schedule SSA (Form 5500)) to a Form 5500 or Form • Print all information necessary in the specific fields
5500-SF required to be filed with the Department of Labor provided on the form.
(DOL) filing system (“EFAST2”). • Do not mark on or near any barcode.
• Do not use glue or other sticky substances on the paper
Mandatory electronic filing. For 2013 and prior years, form.
filers had the option of filing Form 8955-SSA electronically. • Do not staple the form pages. Use binder clips or other
Beginning with the 2014 Form 8955-SSA, however, some fasteners that do not perforate the paper.
filers are now required to file the form electronically. A filer • Do not submit extraneous material or information, such as
must electronically file the 2022 Form 8955-SSA if the filer is arrows used to indicate where to sign, notes between
required to file 250 returns of any type during the calendar preparers of the report, or notations on the form.
year that includes the first day of the plan year. “Returns” for • File Form 8955-SSA using the address specified in the
this purpose include information returns (for example, Forms instructions under Where To File, earlier.
W-2 and 1099), income tax returns, employment tax returns • Use only whole dollars. Round off cents to whole dollars.
(including quarterly Forms 941), and excise tax returns. If a Drop any amount less than 50 cents and increase any
filer is required to file a Form 8955-SSA electronically but amount from 50 to 99 cents to the next higher dollar.
does not, the filer is considered not to have filed the form
even if a paper return is submitted. Penalties
Section 6652(d)(1) imposes a penalty for failure to file a
Note. The instructions are not updated for the applicable registration statement (including failure to include all required
number changes for the mandatory electronic filing participants). The penalty is $10 for each participant not
requirement as amended by the Taxpayer First Act of 2019 reported and for each day multiplied by the number of days
pending guidance. the failure continues. The penalty, up to a maximum of
The requirement to file the 2022 Form 8955-SSA $50,000, is imposed on the person failing to properly file
electronically does not apply to filers filing for relief under unless it is shown the failure is due to reasonable cause.
Notice 2014-35, 2014-23 I.R.B. 1072 (relating to filers who
In the case of a failure to file a notification of a change in
qualify for relief under the Department of Labor’s Delinquent
the status of the plan (such as a change in the plan name or a
Filer Voluntary Compliance Program). See Regulations
termination of the plan), or a change in the name or address
section 301.6057-3 for more information on the mandatory
of the plan administrator, section 6652(d)(2) imposes a
electronic filing of Form 8955-SSA.
penalty of $10 for each day during which such failure occurs.
The IRS may waive the requirements to file Form The penalty, up to a maximum of $10,000, is imposed on the
8955-SSA electronically in cases of undue economic person failing to so file unless it is shown the failure is due to
hardship. For information on filing a request for a hardship reasonable cause.
waiver, see Rev. Proc. 2015-47, 2015-39 I.R.B. 419,
available at IRS.gov/irb/2015-39_IRB/ar16.html, and The Code provides that each plan administrator required
IRS.gov/Retirement-Plans/FAQs-Regarding-Form-8955- to file a registration statement must, before the expiration of
SSA. the time prescribed for the filing of the form, also furnish to
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
Form 8955-SSA on the IRS website at Specific Instructions
IRS.gov/FormsPubs before printing, signing, and mailing it to
the IRS. A barcode capturing the data you entered on the PART I
form will appear on the completed pages when printed. A Enter the calendar or fiscal year beginning and ending dates
form partially completed online and partially completed (other of the plan year (not to exceed 12 months in length) for which
than the signature) on printed paper will cause processing you are reporting information. Express the dates in numerical
delays and may result in correspondence from the IRS. month, day, and year in the following order: (MMDDYYYY).
• Use a printed Form 8955-SSA ordered from the IRS
website at IRS.gov/OrderForms. When completing the form, For a plan year of less than 12 months (short plan year),
use as many pages 2 of the Form 8955-SSA as necessary to enter the short plan year beginning and ending dates on the
list separated participants and number the pages in line provided at the top of the form. For purposes of this form,
sequential order. the short plan year ends on the date of a change in
accounting period or the complete distribution of the plan's
Note. Remember to use additional pages 2 of the 2022 assets.
Form 8955-SSA only if additional pages are needed to add Line A. Check this box if you are electing to file this form
separated participants. Do not use nonstandard pages 2. voluntarily. The plan administrators of plans, such as
Processing tips. To reduce the possibility of governmental plans and non-electing church plans, not
correspondence and penalties: subject to the vesting standards of section 203 of ERISA are
• Sign and date Form 8955-SSA. not required to file this form but may elect to do so. If such a
plan administrator so elects, the plan administrator is

-4- Instructions for Form 8955-SSA (2022)

- 5 -

Page 5 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

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

Instructions for Form 8955-SSA (2022) -5-

- 6 -

Page 6 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Line 4. If the plan administrator's name and/or EIN have Code Use this code for a participant not previously
changed since the most recent Schedule SSA (Form 5500) A reported. Also, complete columns (b) through
or Form 8955-SSA was filed for this plan, enter the plan (g), as applicable.
administrator's name and EIN as they appeared on the most
recently filed Schedule SSA (Form 5500) or Form 8955-SSA. Code Use this code for a participant previously
B reported under the plan number shown on this
Failure to indicate on line 4 that a plan administrator form to modify some of the previously reported
! was previously identified by a different name or EIN information. Enter all the current information for
CAUTION could result in correspondence from the IRS.
columns (b) through (g), as applicable. You do
Line 5. If the plan sponsor's name and/or EIN have changed not need to report a change in the value of a
since the most recently filed Schedule SSA (Form 5500) or participant's account since that is likely to
Form 8955-SSA for this plan, enter the plan sponsor's name, change. However, you may report such a
EIN, and the three-digit plan number as they appeared on the change if you want.
most recently filed Schedule SSA (Form 5500) or Form
Code Use this code for a participant previously
8955-SSA.
C reported under the plan of a different plan
Failure to indicate on line 5 that a plan sponsor was sponsor and who will now be receiving a future
! previously identified by a different name or EIN could benefit from the plan reported on this form.
CAUTION result in correspondence from the IRS.
Also, complete columns (b), (c), (h), and (i).
Line 6a. For a plan to which only one employer contributes, Code Use this code for a participant previously
provide the total number of participants entitled to a deferred D reported under the plan number shown on this
vested benefit who separated from service in the 2021 plan form who is no longer entitled to those deferred
year and who were not previously reported. For a plan to vested benefits. This includes a participant who
which more than one employer contributes, provide the total has begun receiving benefits, has received a
number of participants entitled to a deferred vested benefit lump-sum payout, or has been transferred to
who completed the second of two consecutive 1-year breaks
in service in the 2022 plan year and who were not previously another plan (for example, in the case of a plan
reported. termination). Also, complete columns (b) and
(c). Participants should not be reported under
Line 6b. For a plan to which only one employer contributes,
Code D merely because they return to the
provide the total number of participants entitled to a deferred
vested benefit who separated from service under the plan in service of the plan sponsor.
the 2022 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 Line 9, column (b). Enter the full nine-digit SSN of each
under the plan in 2022 or who completed the first 1-year participant listed. Please do not enter only the last four digits
break in service in the 2022 plan year and who are reported of the SSN. If the participant is a foreign national employed
in Part III of this form. See When To Report a Separated outside the United States who does not have an SSN, enter
Participant. the word “FOREIGN”.
Do not include any participants on line 6a or 6b who Line 9, column (c). Enter each participant's name exactly
as it appears on the participant's social security card. Do not
CAUTION Schedule SSA (Form 5500). Accordingly, only those
! were previously reported on a Form 8955-SSA or a enter periods; however, initials, if on the social security card,
participants who are listed with an Entry Code A on page 2 are permitted.
should be included on line 6a or 6b. After the last name column, there is a checkmark column.
Check the box for each participant whose information is
Line 7. The sum of lines 6a and 6b should equal the number based on incomplete records. Information for a participant
on line 7. may be based on incomplete records where more than one
Line 8. Check the appropriate box as to whether the plan employer contributes to the plan and the records at the end
administrator provided the individual statement to each of the plan year are incomplete regarding the participant's
participant required to receive one. See Penalties. service. Check the box next to a participant's name if:
1. The amount of the participant's vested benefit is based
Signature. Form 8955-SSA must be signed and dated by
on records that are incomplete as to the participant's covered
the plan sponsor and by the plan administrator. If the plan
service (or other relevant service), or
administrator and the plan sponsor are the same person,
include only the signature as plan administrator on the form. 2. The plan administrator is unable to determine from the
If more than one page 2 of the form is filed for one plan, only records of the participant's service if the participant is vested
one page 1 of Form 8955-SSA should be signed and filed in any deferred retirement benefit but there is a significant
with the pages 2 for the plan. likelihood that the participant is vested in such a benefit. See
Regulations section 1.6057-1(b)(3).
PART III
Enter the name of the plan, the plan number, and the plan Line 9, column (d). From the following list, select the code
sponsor's EIN at the top of each page 2. that describes the type of annuity that will be provided for the
participant. Enter the code that describes the type of annuity
Line 9, column (a). Enter the appropriate code from the that normally accrues under the plan at the time of the
following list. participant's separation from service covered by the plan (or,

-6- Instructions for Form 8955-SSA (2022)

- 7 -

Page 7 of 7 Fileid: … s/i8955ssa/2022/a/xml/cycle01/source 17:55 - 14-Sep-2022

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

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

Instructions for Form 8955-SSA (2022) -7-

PDF file checksum: 3249667583

(Plugin #1/9.12/13.0)