OMB No. 1545-0212

rom JOOS Application for Extension of Time Expires 7-31-88

(Rev. August 1985) + eer
to File Certain Employee Plan Returns
Lave File With IRS Only

Department of the Treasury 5 1,
internal Revenue Service > For Paperwork Reduction Act Notice, see Instructions on back.
Name of taxpayer or plan sponsor (see instructions) Check applicable box and enter number (see
File in DUPLI- specific instructions)
CATE by the 1 Employer identification number
due gate for | “Address (Number and street)
return.
(See general
instructions | City or town, State, and ZIP code
2and3)

1 | request an extension of time until (see specific instruction 1) P___............... (check appropriate block(s)):
a ( To file Form 5500, Annual Return/Report of Employee Benefit Plan (with related schedules).

b (1 Tofile Form 5500-C, Return/Report of Employee Benefit Plan (with related schedules).

ec OC Tofile Form 5500-R, Registration Statement of Employee Benefit Plan (with related schedules).

d

O To file Form 5330, Return of Initial Excise Taxes Related to Pension and Profit-Sharing Plans, for tax year beginning >

andending >
e If you checked d above, are you electing to be taxed under ERISA section 2003(c(1(B)Y?. . . ...... O Yes O No
2 Complete the following for the plan covered by this application (see general instruction 2): Plan Plan year ending
Plan name number Month Day | Year
3 a Hasanextension of time to file the designated return(s) been previously granted for thistaxyear? . . . . . O Yes LINo

b_ If Yes,"’ show the date(s) to which the extension was granted

4 Attacha detailed statement of why you need the extension (see specific instruction 4).
5 If the extension is for Form 5330, enter the amount of tax estimated to be due on Form 5330,
Pay this amount with this application .
Caution: /nterest on late payment of tax accrues at ‘he rate established under section 6621 oF hs Internal Revenue Code from the regular
due date of the return until paid. (For the penalty for late payment of tax, see specific instruction 5.)

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

Signature Date >

Note: The person who signs this form may be an employer or plan administrator filing Form 5500, 5500-C, 5500-R or 5330; a
disqualified person filing Form 5330; an attorney or certified public accountant qualified to practice before the IRS; a person
enrolled to practice before the IRS; or a person holding a power of attorney.

Notice to Applicant.—The Internal Revenue Service will indicate below whether the extension is granted or denied and will return the
original of the application.

0 The application IS approved to Poo eee (You MUST attach a copy of this form
to each return you file for which an extension is granted.)

0 The application 1S NOT approved. (You MUST attach a copy of this form to each return you file for which a grace period is granted.)
However, in view of your reasons stated in the application, a 10-day grace period is granted from the date shown below or due date of

the return, whichever is later. This 10-day grace period’ constitutes a valid extension of time for purposes of elections otherwise
required to be made on timely filed returns.

1 The application IS NOT approved.

After consideration of the reasons stated in your application, we have determined the extension is not warranted. (The 10-day grace
period is not granted.)

The application cannot be considered, since you filed it after the due date of the return.

Other mee ee eee cee ee ee ee cen eee eee ee ee ee eeee

oo

By:

(Date) (Director)

Form 5558 (Rev. 8-85)


Form 5558 (Rev. 8-85)

Page 2

If you want the original of this application returned to an address other than that shown on page 1, please fill in the

address below.

Name
Please
Print Address (Number and street)
or
Type City or town, State, and ZIP code

General Instructions

Paperwork Reduction Act Notice.—The
Paperwork Reduction Act of 1980 says we
must tell you why we are collecting this
information, how we will use it and whether
you have to give it to us. We ask for it to
carry out the Internal Revenue laws of the
United States. We need it to determine if
you are entitled to an extension of time to
file your employee plan returns. If you want
such an extension you are required to give
us this information.

1. Purpose.—Form 5558 may be used to
apply for an extension of time to file Form
5500, 5500-C, 5500-R, or 5330. No
extension will be granted if you are electing
to be taxed under section 2003(c)(1)(B) of
the Employee Retirement Income Security
Act of 1974 (ERISA).

2. How and Where to File.—In general,
you must file a separate Form 5558 for
each return for which you are requesting an
extension. However, if you are a single
employer and all of your plan years end on
the same date, you may file one Form 5558
to request an extension of time to file more
than one Form 5500, 5500-C, or 5500-R.
Attach a list showing the plan names and
numbers of all of the plans for which you
are requesting an extension and show the
month, day, and year the plan year ends.
Complete this form in duplicate and file it
with the Internal Revenue Service Center
where you will file your Form 5500, 5500-C,
5500-R, or 5330. See the instructions for
the form you intend to file for a list of
locations.

3. When to File.—You should file this
application in sufficient time for the Internal
Revenue Service to consider and act on it
before the return’s regular due date.

Specific Instructions

Name and address.—If you are a single
employer and are requesting an extension
to file the annual return/report Forms
5500, 5500-C, or 5500-R, you must enter
your name and address in the heading. If
you are filing for other than a single
employer, enter the plan sponsor's name.
and address on the application. The plan
sponsor listed on this application should be
the same as the plan sponsor listed on the
annual return/report filed for the plan.
Employer identification number or social
security number.—If you are filing this
application for an extension of time to file
Form 5330 and you made excess
contributions to a Code section
403(b)(7)(A) custodial account or you area
disqualified person other than an employer,
enter your social security number. In all
other cases, enter the employer
identification number of the person listed in
the name and address block.

Line 1.—Check the box or boxes to indicate
the return for which you are requesting an
extension.

If your application for an extension to file
Form 5500, 5500-C, or 5500-R, is
approved, you will be granted an extension
of not more than 24 months.

Note: /f you are filing for a single employer
plan or for a plan of a controlled group of
corporations that file a consolidated income
tax return and the plan year and the tax year
coincide, and have been granted an
extension of time to file your income tax
return to a date that is beyond the due date
of the Forms 5500, 5500-C, and 5500-R,
then the extension also applies to the Forms
5500, 5500-C, and 5500-R.

Attach a copy of the approved IRS
extension to file the income tax return to
each Form 5500, 5500-C, and 5500-R that
is filed after the normal due date.

If your application for extension of time
to file Form 5330 is approved, you may be
granted an extension of up to six months.

Line 4.—Attach a detailed statement
explaining why you need an extension. The
Internal Revenue Service will grant a
reasonable extension of time for filing a
return if you file a timely application
showing that you are unable to file the
return because of circumstances beyond
your control. Generally, an application will
be considered on the basis of your own
efforts to fulfill this filing responsibility,
rather than the convenience of anyone
providing help in preparing the return.
However, consideration will be given to any
circumstances that prevent your
practitioner, for reasons beyond his or her
control, from filing the return by the due
date, and to circumstances in which you are
unable to get needed professional help in
spite of timely efforts to do so.

Applications that give incomplete
reasons, such as “‘illness’’ or ‘‘practitioner
too busy,’’ without adequate explanations,
will not be approved. If it is clear that a
request for extension is frivolous, solely to
gain time, the Internal Revenue Service will
deny both the extension request and the
10-day grace period.

Line 5.—If you are applying for an
extension of time to file Form 5330,
estimate the amount of tax due with Form
5330 and enter the total on line 5.

The extension of time to file does not
extend the time to pay the tax due.
Therefore, you must pay the amount of tax
due with this application.

The law imposes a penalty for late
payment of tax. The penalty is ¥ of 1% of
the unpaid amount for each month or part
of a month it remains unpaid. The
maximum penalty is 25% of the unpaid
amount,

Interest is also charged at the rate
provided by law from the due date of the
return until the date the tax is paid.