rom 9558 Application for Extension of Time wit Rs

(Rev. Feb, 1978) ‘.
Department of the Treasury to File Certain Employee Plan Returns Only

Internal Revenue Service

File in TRIPLI-] Name of taxpayer, employer or plan administrator (see instructions) Check applicable box and enter number (see
CATE on or be- specific instructions)

fore the due . tas,

date for filing | Address (Number and street) [] Employer identification number

the return.

(See general

instructions | City or town, State, and ZIP code (CJ Social security number
2 and 3.) >

1 An extension of time until (see specific instruction 1) >... is hereby requested in which (check appropriate block(s)):
(a) [J To file Form 5500, Annual Return/Report of Employee Benefit Plan (with related schedules).

(b) [] To file Form 5500-C, Annual Return/Report of Employee Benefit Plan (with related schedules).
(c) [) To file Form 5500-K, Annual Return/Report of Employee Pension Benefit Plan (with related schedules).
(d) [J To file Form 5330, Return of Initial Excise Taxes Related to Pension and Profit-Sharing Plans.

(e) If you checked (d) above, are you electing to be taxed under section 2003(c)(1)(B) of ERISA?. . . . .[] Yes [J No
(f) If you checked (d) above, enter the employer identification number of the plan sponsor. . . D.......
2 For taxable year (complete only if 1(d) is checked) beginning > . and ending >...
3 Complete the following for the plan covered by this application (see general instruction 1 Plan Plan year ending.
Plan name number Month] Day Year
4 (a) Has an extension of time to file the designated return(s) been previously granted for this taxable year? . . [] Yes [] No
(b) If “Yes,"" show the date(s) to which the extension was granted (attach list if needed)... D> -
(c) If you checked 1(a), (b), (c) or (d), have you been granted an extension of time to file your Federal income tax
return? . 2 we . soe ee ee ee ee ew ee ee EJ Yes (No

(d) If 4(c) is “Yes,” enter the date to ‘which the extension was granted .
(e) If you have not received an answer to your application for extension of time to file your Federal income tax
return, insert “applied for’ and enter your social security number, if applicable. >.

5 Attach a detailed statement as to why you need the extension (see specific instruction 5).
6 If the extension is for Form 5330, pay the amount of tax estimated to be due on Form 5330 with this application

(see specific instruction 6). Enter the amount ofthetax here. . . . . . . . >
Caution: Interest on late payment of tax accrues at the rate established pursuant to section 6621 of the Internal Revenue Code from
the regular due date of the return until paid. (For the amount of penalty due to late payment of tax see specific instruction 6.)

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

[ An employer filing Forms 5500, 5500-C, 5500-K or 5330.

CO Aplan administrator filing Forms 5500, 5500-C, 5500-K or 5330.

A disqualified person, other than an employer, filing Form 5330.

CO An individual filing Form 5330 to pay tax on excess contributions to a section 403(b)(7)(A) custodial account or a Keogh (H.R.
10) plan.

[J A member in good standing of the bar of the highest court of (specify jurisdiction) D> __

(DA certified public accountant duly qualified to practice in (specify jurisdiction) > _

[A person enrolled to practice before the Internal Revenue Service.

O Aduly authorized agent holding a power of attorney. The power of attorney need rot be submitted unless requested.

Signature p> Date p>

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

.- (Please attach this form to the return.)

[J The application IS approved to D>.

(J The application IS NOT approved. (Please attach ‘this form to the return.)
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.

(O 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 >

Date Director

244-410-1 By:



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

address below.

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

General Instructions

1. Who May File.—Any of the persons
listed on page 1, immediately above the
signature, may use this application to
request an extension of time to file the
applicable return(s) listed under line 1,
page 1. In general, a separate Form
5558 must be filed for each return for
which an extension is requested.

Exception: One Form 5558 may be
used to request an extension of time to
file Forms 5500, 5500-C and 5500-K
for all of a single employer's plans which
have plan years ending on the same date.
Attach a list, in the same format as line
3 on page 1, of all the plans for which
additional time to file Forms 5500,
5500-C and 5500-K is requested.

2. When to File—You must file the

application in sufficient time for the In-
ternal Revenue Service to consider and
act on it before the return’s regular due
date.

3. How and Where to File.—Complete
this form in triplicate and file it with the
appropriate office shown in the list below.

If the principal place of
business, office or agen-
cy (or legal residence,
if you have no principal
place of business or of-
fice or agency in the
United States), is lo-
cated in

Vv

New Jersey, New York
City and counties of
Nassau, Rockland,
Suffolk, and
Westchester

New York (all other.
counties), Connecticut,
Maine, Massachusetts,
New Hampshire, Rhode
Island, Vermont

Use this address

Internal Revenue Service
Center
Holtsville, NY 00501

Internal Revenue Service
Center
Andover, MA 05501

District of Columbia,
Delaware, Maryland,
Pennsylvania

Internal Revenue Service
enter
Philadelphia, PA 19255

Alabama, Florida,
Georgia, Mississippi,
South Carolina

Internal Revenue Service
Center
Atlanta, GA 31101

Michigan, Ohio Internal Revenue Service

Center
Cincinnati, OH 45999

Arkansas, Kansas,
Louisiana, New Mexico,
Oklahoma, Texas

Internal Revenue Service
Center
Austin, TX 73301

Alaska, Arizona,
Colorado, Idaho,
Minnesota, Montana,
Nebraska, Nevada,
North Dakota, Oregon,
South Dakota, Utah,
Washington, Wyoming

Internal Revenue Service
enter
Ogden, UT 84201

Ulinois, lowa, Missouri, Internal Revenue Service
Wisconsin enter
Kansas City, MO 64999

Page 2

Internal Revenue Service
Center
Fresno, CA 93888

California, Hawaii

Indiana, Kentucky, _ Internal Revenue Service
North Carolina,
Tennessee, Virginia,

West Virginia

Center
Memphis, TN 37501

If you have no legal residence, principal place
of business or principal office or agency in any
Internal Revenue district, file your return with
the Internal Revenue Service Center, Philadelphia,
PA 19255.

Specific Instructions

(Numbered to correspond to lines on
the application)

Name and Address.—The employer's
name and address must be entered in
the heading of the application in all
cases when it is filed for a single em-
ployer requesting an extension to file
Form 5500, 5500-C or 5500-K.

Employer Identification Number or
Social Security Number.—If this applica-
tion is being filed for Form 5330 by an
individual who made excess contributions
to either a section 403(b)(7)(A) custo-
dial account or a Keogh (H.R. 10) plan
or who is a disqualified person other than
an employer, then the individual's social
security number should be entered in the
appropriate blank. All others filing this
application should enter their employer
identification number.

1. Extension Period.—This applica-
tion form may be used to request an ex-
tension for one return only unless the
exception in General Instruction 1 ap-
plies.

An extension of time to file Forms
5500, 5500-C and 5500-K may be
granted for a period not in excess of 24%
months.

Note: Single employer plans and plans
of a controlled group of corporations
which file a consolidated income tax re-
turn where the plan year and the tax
year coincide and the single employer or
controlled group has been granted an
extension to file its income tax return
beyond the due date of the Forms
5500, 5500-C and 5500-K, such
extension also applies to the Forms
5500, 5500-C and 5500-K. A copy of
the approved IRS extension to file the
income tax return must be attached to
the Form 5500, 5500-C or 5500-K
that is filed after the normal due date.

If circumstances warrant, an extension
of time up to but not more than six

‘¥y U.S. GOVERNMENT PRINTING OFFICE : 1978—O-244-410

months may be granted for filing Form
5330. However, no extension will be
granted if you are electing to be taxed
under section 2003(c)(1)(B) of the Em-
ployee Retirement Income Security Act
of 1974 (ERISA).

5. Reasons for Extension.—The In-
ternal Revenue Service will grant a rea-
sonable extension of time for filing a re-
turn if a timely application is filed that
establishes the taxpayer's inability to file
the return because of circumstances be-
yond his or her control. Generally, an
application will be considered on the
basis of the taxpayer’s own efforts to
fulfill this filing responsibility, rather
than the convenience of anyone provid-
ing assistance in preparing the return.
However, consideration will be given to
any circumstances that prevent the tax-
payer’s practitioner, for reasons beyond
his or her control, from filing the return
by the due date, and to circumstances in
which a taxpayer has been unable to get
needed professional help in spite of
timely efforts to do so.

You should clearly describe in your
answer to line 5 the circumstances
which will cause unavoidable delay in
filing the return. Applications that give
incomplete reasons, such as “‘illness’’ or
“practitioner too busy,’’ without ade-
quate explanations, will not be approved.
If it is clear that a request for extension
is frivolous, solely to gain time, the In-
ternal Revenue Service will deny both
the extension request and the 10-day
grace period.

6. Payment of Tax.—The total amount
of tax estimated to be due must be paid
in full on or before the normal due date
of the return, which is the last day of
the 7th month following the close of the
taxable year. The amount of tax esti-
mated to be due as shown on line 6 must
be paid with this application.

An extension of time to file a Form
5330, unless it specifies otherwise,
does not extend the time for payment of
tax due. The law imposes a penalty for
late payment of tax figured at one-half
percent a month or fractional part of a
month not to exceed 25 percent.

Interest accrues at a rate set pur-
suant to section 6621 of the Code on
any tax due on the return from the reg-
ular due date until paid.

244-410-1