OMB No. 1545-0212

Expires 5-31-95

Form 5558 Application for Extension of Time

(Rev. June 1992) To File Certain Employee Plan Returns

Department of the Treasury

Internal Revenue Service File With IRS Only © For Paperwork Reduction Act Notice, see instructions on back.

Name of taxpayer or plan sponsor (see instructions)

File before

the due date

for filing the

return (see

instructions)

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

City or town, state, and ZIP code Social security number. Form 5330 filers see instructions.

©

1 I request an extension of time until (see instructions) © (check appropriate block(s)):

a To file Form 5500, Annual Return/Report of Employee Benefit Plan (with related schedules).

b To file Form 5500-C/R, Return/Report of Employee Benefit Plan (with related schedules).

c To file Form 5500EZ, Annual Return of One-Participant Pension Benefit Plan (with related schedules).

To file Form 5330, Return of Excise Taxes Related to Employee Benefit Plans, for tax year beginning ©

and ending ©

d

2 If you checked 1d above, are you electing to be taxed under ERISA section 2003(c)(1)(B)? Yes No

3a If you have never filed a Form 5500, 5500-C/R, or 5500EZ for your plan, check this box ©

If you checked 3a, enter the name, address, and EIN of the plan administrator ©

4 Complete the following for the plan(s) covered by this application (see How To File): Plan Plan year ending

Plan name number Month Day Year

5a Has an extension of time to file Form 5330 been previously granted for this tax year? Yes No

b If “Yes,” enter the date(s) for which the extension was granted ©

6 Attach a detailed statement explaining why you need the extension (see instructions).

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 ©

7

Caution: Interest on a late payment of tax accrues at the rate established under section 6621(a)(2) of the Internal Revenue Code from the

regular due date of the return until paid. (See specific instructions for the penalty for late payment of tax.)

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 ©

Note: The person who signs this form may be an employer or plan administrator filing Form 5500, 5500-C/R, 5500EZ, 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 this

application to you.

This application IS approved to © (You MUST attach a copy of this form

to each return that was granted an extension.)

This application IS NOT approved. However, in view of the reasons stated in the application, a 10-day grace period is granted from

the date shown below or the 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 a timely filed return. (You MUST attach a copy of this form to each return

you file that is granted a grace period.)

This application IS NOT approved. After consideration of the reasons stated in your application, we have determined that an extension

is not warranted. (The 10-day grace period is not granted.)

This application cannot be considered, because it was filed after the due date of the return.

This application cannot be considered because the maximum extension of time allowed is 21⁄2 months (6 months for Form 5330).

Other ©

(Date) (Director)

© OR

Employer identification number (EIN). Filers checking any

box in 1a through 1d must enter an EIN. All other filers

see specific instructions.

By:

Form 5558 (Rev. 6-92)

b

Identification Number.—Check applicable box and enter

number (see instructions).
Form 5558 (Rev. 6-92) Page 2

If you want Form 5558 returned to an address other than that shown on page 1, please fill in the address below.

Name

Please

Print

or

Type

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

City or town, state, and ZIP code

When To File

General Instructions

Paperwork Reduction Act Notice

Specific Instructions

Name and Address

If your application for extension of time to

file Form 5330 is approved, you may be

granted an extension of up to 6 months.

Line 6

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated time is: 36

minutes.

If you have comments concerning the

accuracy of this time estimate or suggestions

for making this form more simple, we would

be happy to hear from you. You can write to

both the Internal Revenue Service,

Washington, DC 20224, Attention: IRS

Reports Clearance Officer, T:FP; and the

Office of Management and Budget,

Paperwork Reduction Project (1545-0212),

Washington, DC 20503. DO NOT send the

tax form to either of these offices. Instead,

see Where To File.

Identification Number

Purpose of Form

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.

Caution: If we grant you an extension of time

to file and later find that the statements made

on this form are false or misleading, the

extension will be null and void. A late filing

penalty associated with the form for which

you filed this extension will be charged.

Employers who do not have an EIN may

apply for one by attaching a completed Form

SS-4 to this form.

Line 1

Line 7

How To File

If your application for an extension of time

to file Form 5500, 5500-C/R, or 5500EZ is

approved, you will be granted one extension

of not more than 21⁄2 months.

An extension of time to file does not extend

the time to pay the tax due. Any tax due

must be paid with this application.

Exception: Form 5500, 5500-C/R, or 5500EZ

filers are automatically granted extensions of

time to file until the extended due date of the

Federal income tax return of the employer

(and are not required to file Form 5558) if all

the following conditions are met: (1) the plan

year and the employer’s tax year are the

same; (2) the employer has been granted an

extension of time to file its Federal income tax

return to a date later than the normal due

date for filing Form 5500, 5500-C/R, or

5500EZ; and (3) a copy of the IRS extension

of time to file the Federal income tax return is

attached to the Form 5500, 5500-C/R, or

5500EZ filed with the IRS. An extension

granted under this exception CANNOT be

extended further by filing a Form 5558 after

the normal due date (without extension) of the

annual return/report.

Late Payment of Tax

Interest

Where To File

We ask for the information on this form 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 an

extension, you are required to give us the

information.

Use Form 5558 to apply for a one-time

extension of time to file Form 5500,

5500-C/R, 5500EZ, or 5330. An extension will

not 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).

In general, a separate Form 5558 is used 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, file only one Form 5558 to

request an extension of time to file more than

one Form 5500, 5500-C/R, or 5500EZ. Attach

a list showing the name and number of all of

the plans for which you are requesting an

extension and show the month, day, and year

the plan year ends.

File Form 5558 with the Internal Revenue

Service Center where you will file your

Form 5500, 5500-C/R, 5500EZ, or 5330.

See the instructions for the return/report

you intend to file for a list of locations.

File Form 5558 in sufficient time for the

Internal Revenue Service to consider and act

on it before the return’s regular due date.

Form 5500, 5500-C/R, and 5500EZ filers, see

the specific instructions for line 1.

Enter your name and address in the heading

if you are a single employer requesting an

extension of time to file the annual

return/report Form 5500, 5500-C/R, or

5500EZ. 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.

Include the suite, room, or other unit

number after the street address. If the Post

Office does not deliver mail to the street

address and you have a P.O. box, show the

P. O. box number instead of the street

address.

Enter the nine-digit employer identification

number (EIN) assigned to the employer for all

applications filed for Forms 5500, 5500-C/R,

and 5500EZ. Also enter the employer’s EIN

for applications filed for Form 5330, unless

you made excess contributions to a Code

section 403(b)(7)(A) custodial account or you

are a disqualified person other than an

employer. If you did make excess

contributions as described above or are a

disqualified person other than an employer,

enter your social security number.

Check the boxes to indicate the returns for

which you are requesting an extension.

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.

If this is an application to extend the time to

file Form 5330, enter the amount of tax

estimated to be due with Form 5330 on

line 7.

Interest is charged on taxes not paid by the

due date even if an extension of time to file is

granted.

The penalty for late payment of taxes is

usually 1⁄2 of 1% of the unpaid tax for each

month or part of a month the tax is unpaid.

The penalty cannot exceed 25% of the

amount due. This penalty may also apply to

any additional tax not paid within 10 days of

notice and demand for payment.

A Change You Should Note

Duplicate filing of this form is no longer

required.