Form 5558 - Application For Extension Of Time To File Certain Employee Plan Returns

5558

Application for Extension of Time

OMB No. 1545-0212

To File Certain Employee Plan Returns

Form

(Rev. August 2012)

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

File With IRS Only

Department of the Treasury

Information about Form 5558 and its instructions is at

Internal Revenue Service

Part I

Identification

A

Name of filer, plan administrator, or plan sponsor (see instructions)

B

Filer’s identifying number (see instructions)

Employer identification number (EIN) (9 digits XX-XXXXXXX)

Number, street, and room or suite no. (If a P.O. box, see instructions)

Social security number (SSN) (9 digits XXX-XX-XXXX)

City or town, state, and ZIP code

C

Plan year ending—

Plan

Plan name

number

DD

YYYY

MM

Part II

Extension of Time To File Form 5500 Series, and/or Form 8955-SSA

Check this box if you are requesting an extension of time on line 2 to file the first Form 5500 series return/report for the plan listed

1

in Part 1, C above.

2

I request an extension of time until

/

/

to file Form 5500 series (see instructions).

Note. A signature IS NOT required if you are requesting an extension to file Form 5500 series.

3

I request an extension of time until

/

/

to file Form 8955-SSA (see instructions).

Note. A signature IS NOT required if you are requesting an extension to file Form 8955-SSA.

The application is automatically approved to the date shown on line 2 and/or line 3 (above) if: (a) the Form 5558 is filed on or before

the normal due date of Form 5500 series, and/or Form 8955-SSA for which this extension is requested, and (b) the date on line 2

and/or line 3 (above) is not later than the 15th day of the third month after the normal due date.

Extension of Time To File Form 5330 (see instructions)

Part III

4

I request an extension of time until

/

/

to file Form 5330.

You may be approved for up to a 6 month extension to file Form 5330, after the normal due date of Form 5330.

a

Enter the Code section(s) imposing the tax

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a

b

Enter the payment amount attached .

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b

c

For excise taxes under section 4980 or 4980F of the Code, enter the reversion/amendment date .

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c

5

State in detail why you need the extension:

Under penalties of perjury, I declare that to the best of my knowledge and belief, the statements made on this form are true, correct, and complete, and that I am authorized

to prepare this application.

Date

Signature

5558

Form

(Rev. 8-2012)

Cat. No. 12005T