Print Form
5558
Application for Extension of Time
OMB No. 1545-0212
Form
To File Certain Employee Plan Returns
(Rev. August 2012)
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
File With IRS Only
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Department of the Treasury
Information about Form 5558 and its instructions is at
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Internal Revenue Service
Part I
Identification
A
B
Name of filer, plan administrator, or plan sponsor (see instructions)
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.
Part III
Extension of Time To File Form 5330 (see instructions)
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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b
Enter the payment amount attached .
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c
For excise taxes under section 4980 or 4980F of the Code, enter the reversion/amendment date .
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c
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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.
Signature
Date
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5558
Form
(Rev. 8-2012)
Cat. No. 12005T