Free 2008 Form 5500 Schedule SSA - Federal

Attention:
Telephone requests for the forms, schedules, and instructions for the 2008 Form 5500-series will not be filled until December 10, 2008. Requests for the 2008 Form 5500-series products can be made on the Internet (see below) beginning December 10, 2008. Requests made prior to that date will be filled with the 2007 version of the products. The product you are about to view is provided for information purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The Forms 5500 and 5500-EZ (and related schedules) are printed on special paper with dropout ink so they can be processed by the computerized processing system "EFAST." These forms and schedules may be obtained by calling 1-800-TAX-FORM (1-800-829-3676). Be sure to order using the IRS form number. Note: You can also use the Internet link Forms and Publications by U.S. Mail to request a limited number of these forms and schedules. Check the Department of Labor's website at www.efast.dol.gov for additional information concerning the processing system, electronic filing, software, and "non-standard" filings. Note: There is no Schedule B (Form 5500) for filing 2008 plan year actuarial information. Instead, file the 2008 Schedule MB (Form 5500), Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information, or the Schedule SB (Form 5500), Single-Employer Defined Benefit Plan Actuarial Information, as applicable. For only plan year 2008 filings, paper Schedules MB and SB are provided in the format presented for completion by pen or typewriter. ________________________________________________

Official Use Only

SCHEDULE SSA (Form 5500)

Annual Registration Statement Identifying Separated Participants With Deferred Vested Benefits
Under Section 6057(a) of the Internal Revenue Code

OMB No. 1210-0110

2008
This Form is NOT Open to Public Inspection.

Department of the Treasury Internal Revenue Service



File as an attachment to Form 5500 unless box 1 is checked.

and ending

A

Name of plan

C

Plan sponsor's name as shown on line 2a of Form 5500

B

1

3a Name of plan administrator (if other than sponsor)

Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct, and complete. Phone number of Signature of plan administrator plan administrator

FO

R

City or town

IN

FO

3c Number, street, and room or suite no. (If a P.O. box, see the instructions for line 2.)

RM

3b Administrator's EIN

AT

IO

NA

L

PU

RP

City or town

O

SE

S

2

Plan sponsor's address (number, street, and room or suite no.) (If a P.O. box, see the instructions for line 2.)

O

NL

Check here if plan is a government, church or other plan that elects to voluntarily file Schedule SSA. If so, complete lines 2 through 3c, and the signature area.

Y,

D

O

Three-digit plan number

D

Employer Identification Number



NO

T

State

US E
ZIP code State ZIP code





SIGN HERE

Date

MM / D D / Y Y Y Y
Cat. No. 13506T Schedule SSA (Form 5500) 2008

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

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v11.3

FO

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FI LI NG

For calendar plan year 2008 or fiscal plan year beginning

MM / D D / Y Y Y Y

MM / D D / Y Y Y Y

Schedule SSA (Form 5500) 2008 4

Page

2
Official Use Only

Enter one of the following Entry Codes in column (a) for each separated participant with deferred vested benefits that: Code A -- has not previously been reported. Code B -- has previously been reported under the above plan number but requires revisions to the information previously reported. Code C -- has previously been reported under another plan number but will be receiving their benefits from the plan listed above instead. Code D -- has previously been reported under the above plan number but is no longer entitled to those deferred vested benefits.

Use with entry code "A", "B", "C", or "D"
(a) Entry code (c) Name of participant (First) (b) Social security number (M. I.) (Last)

US E

Enter code for nature and form of benefit (d) Type of annuity (e) Payment frequency (f) Defined benefit plan -- periodic payment

Amount of vested benefit Defined contribution plan (g) Units or shares

FO

Use with entry code "A" or "B"

R

FI LI NG

Share indicator









.

(h) Total value of account

O

NO








(j) Previous plan number

.

T

(i) Previous sponsor's employer identification number

Use with entry code "C"

(a) Entry code (c) Name of participant (First)

RP

O

Use with entry code "A", "B", "C", or "D"
(b) Social security number (M. I.) (Last)

Use with entry code "A" or "B"

IO

NA

L

PU

AT

Enter code for nature and form of benefit (d) Type of annuity (e) Payment frequency

SE

Amount of vested benefit Defined contribution plan (g) Units or shares

S

O

NL

Y,

D

.

(f) Defined benefit plan -- periodic payment

RM

Share indicator

FO







.








(j) Previous plan number

. .

(h) Total value of account

FO

R

IN

(i) Previous sponsor's employer identification number

Use with entry code "C"

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