ERISA Form 8955-SSA 2-D Barcode Standards. Version 1.3 June 7, 2012

Transcription

1 ERISA 8955-SSA 2-D Barode Standards Versi 1.3 June 7, 2012 Plan Years:

2 History Log Versi Date Summary of Changes Editor /14/2011 Versi 1.0 WBAPSO/CIT 1.1 6/27/ Update Barode Spes: Page 2 WBAPSO/CIT Barode 1, #6 Software Versi should be a 2 positi numeri field speifying vendor software versi (0, 1, 2, 3, et.) - Add details about ft for page data under the Approval Proedures seti - Update Plan Name Page 2 Barode 1, #9 Notes should make referene to repeating Plan Name from Seti 1a, not Seti 1b - s: Amounts no lger show deimals in print format /01/ Adding SSA WBAPSO/CIT - Barode is Mandatory for SSA Approval - New Seti 7: Printing/Notes o Printing Data Fts/Sizes o Vendor ID to print in top left orner o Address field updates - Update Approval Proedures vendor informati 1.3 6/7/ Added a note about arriage returns in WBAPSO/CIT the barode to the General Standards seti - Update Links to State and Country at the end of the Barode Layout seti - Update Title Page and Overview seti to reflet plan years for whih this doument is valid ( )

3 ERISA 8955-SSA - 2D Barode Standards Ctents 1. Overview 1 2. General Standards 2 3. Approval Proedures 2 4. Durati of Approvals 3 5. Barode Speifiatis 3 6. Rules 4 7. Versis and Printing Notes 5 8. s SSA Barode Layout 8 a. Page 1 - Barode 1 (bottom left side) 8 b. Page 1 - Barode 2 (bottom right side) 12. Page 2 - Barode 1 (bottom left side) 16 d. Page 2 - Barode 2 (bottom right side) 27

4 1. Overview This doument overs ly the 2D barode ERISA 8955-SSA valid for Plan Years The 2D barode is intended to represent the informati the paper form. Barodes for this form are generated from two soures: 1. The IRS 8955-SSA Fill-able PDF produes a barode after printing the form in Adobe. 2. The approved software vendors for 8955-SSA produe a barode when printing their forms from their software pakages. The first page of the form tains informati about the Plan Administrator and Plan Spsor, as well as annual statement identifiati data and signatures. This page must have two barodes, and the tent for eah barode is defined in the barode layout seti (see Seti SSA Barode Layout). The signature and signed dates are the ly data fields not inluded in the barodes; all other fields are inluded in the barode data. When generating your output file, the bottom of page 1, you will provide a page number whih will indiate this is page 1 of X. Where X is equal to the total number of pages in this submissi. (You an referene the offiial IRS PDF file for orret plaement of this informati.) The sed page of the form tains partiipant informati, suh as the name, soial seurity number, and informati about the partiipant s benefits. The form will allow ten partiipants eah page 2, and multiple page 2 s an be submitted for more partiipants. Eah page 2 must have two barodes as defined in the layout (see Seti SSA Barode Layout). All data this page should be inluded in the barode. On page 2, you will display a number in the upper right orner of the page, identifying the orret page number (i.e. the first page 2 in your submissi will have printed the page, in this loati, page 2.1 If you have additial page 2 s, you must number them to indiate that they are additial. The next page 2 for this submissi would be numbered 2.2, and so.) You must also indiate the page, the orret (whole number) page number (i.e. page 3 of 4, page 5 of 6.) (You an referene the offiial IRS PDF file for orret plaement of this informati.) Refer to the form samples provided by the IRS (PDF 8955-SSA) for proper layout (labels, graphis, tent, lines, sale, margins, et.). If a software developer does not support 2-D barodes, the area reserved for the barode must be left blank. A general rule that an be used to determine if a printer is apable of produing a 2-D barode is that, if the printer an produe a graphi suh as an ageny seal or business logo, then the printer should be apable of produing a 2-D barode that an be sanned. 1 of 41

5 2. General Standards The barode will be a 2-D barode in the PDF-417 format. The PDF 417 has error deteti and orreti apabilities. The error orreti level should be set to level 5. All fields within the barode are followed by a arriage return delimiter - <CR>. o NOTE Please do not insert a arriage return within the Plan Name field. It may appear as two lines the form to fit all 140 haraters, but do not use any delimiter in the barode between the two lines of text. Doing so will make the barode invalid. All fields are required, although a field an be left empty (leaving just the field terminating <CR>). Do not zero fill or fill with spaes if a field is to be left blank, unless otherwise speified. If there is no data, a field should be left empty followed by a terminating <CR>. It is up to the deoder to determine how to handle empty fields. Strething or saling the barode hanges its integrity and redues the readability of the barode; please do not streth or sale the barode. The barode must be surrounded by at least 1/4 of whitespae. Barodes are required vendor forms in order to obtain SSA Approval for 8955-SSA. 3. Approval Proedures Software vendors should provide up-to-date tat informati inluding aurate addresses when submitting forms for approval. Test senarios for 2-D barode testing are via PDF. The format of the and the 2-D barode data will be approved separately and simultaneously, if possible, to expedite the approval proess. SSA will indiate exatly what is being approved. SSA requests 2 sheets of forms with test data for approval. If submitting a 2-D barode for approval, at least e sheet with 2-D barode sample must be a maxfill sample. Samples with data fields that are maximum filled must have data in all fields. The data in the remaining 2-D barode samples should reflet the data the sheets, inluding field inlusi or exlusi requirements based ertain data speified. Example: Entry Code C Page 2 requires data in the Previous Spsor s EIN and Previous Plan Number fields, but require no data in the Defined benefit Plan Periodi Payment and Total Value of Aount fields. SSA requests e printout of a blank form (without data and without a barode). The vendor number must be inluded in the barode per barode layout in Seti 8 of this doument. It must also be printed at the top of the form per speifiatis. The SSA an provide vendor odes for n-nactp 1 submissis. 1 The Natial Assoiati of Computerized Tax Proessors (NACTP) is a nprofit assoiati that represents tax proessing software and hardware developers, eletri filing proessors, tax form publishers, and tax 2 of 41

6 Please use a fixed pith ft for the printed data 8955-SSA, preferably Courier New. Please ensure that the data in eah field fits in the appropriate box the form when printed. Please see Seti 7 of this doument for ft size details. Any questis or submissis for the 8955-SSA barode speifiatis should be ed to: erisa.forms@ssa.gov, or sent to: Soial Seurity Administrati Data Operatis Center Attn: Erisa s Approval, Room E. Mountain Drive Wilkes-Barre, PA The following informati should be inluded with the test sheets, either a over page or in the body of the - Date of Request - Company Name - Address - Ctat Name / Title / Phe - - Software Produt - Software Produt Website - Software Produt Sales Phe - Vendor ID - for approval 4. Durati of Approvals Approvals are valid for ly e tax year (January through Deember) In general, eah new filing seas requires new approval, even if the offiial form does not hange. 5. Barode Speifiatis The barode is defined as a 2-D barode in the PDF-417 format. The PDF 417 has error deteti and orreti apabilities. The error orreti level should be set to level 5. All fields within the barode will use <CR> as a field delimiter (arriage returns after eah field, inluding the final *EOD* field). All fields are required, exept where not appliable for speifi entry odes (see Seti SSA Barode Layout). If no data is provided, the barode data for that field will be blank followed by the <CR> delimiter. Exepti: Mandatory data fields may not be left empty. proessing servie bureaus. The assoiati enourages standardizati of tax forms and the eletri filing proess. 3 of 41

7 If there is no data for a field entry, the field should be left empty. Do not zero fill or pad with spaes if a field is to be left blank. Exepti: Plan Numbers should be left zero filled. Strething or saling the barode hanges its integrity and redues the readability of the barode; it should not be de. The barode must be surrounded by at least 1/4 of whitespae. Provide an End of Data field at the end of eah barode ( *EOD* followed by a <CR>). Provide appropriate header informati for eah page in the first barode per page (as defined in Seti 8). o Header, Developer Code, Jurisditi, and Number Please note the printed Developer Code should appear at the top left of the form. (see barode spes for this field). o Speifiati Versi must be updated as revisis are made o Software Versi must be maintained aurately 6. Rules Mey fields must: o Ctain ly numbers o No puntuati o No signed amounts (high order signed or low order signed) o No negative amounts o Round to the nearest dollar (example: $5, = 5501) Address s o Must form to U.S. Postal Servie rules sine address fields are used by SSA to prepare mail orrespdene if neessary. For more informati: See U.S. Postal Servie Publiati 28; or View the U.S. Postal Servie website at: pe.usps.om/businessmail101/addressing/deliveryaddress.htm Call the U.S. Postal Servie at o For State, use ly the two-letter abbreviatis o FOREIGN addresses are not validated in the SSA proessing, but should form to regial standards as appropriate. Employer EIN o Only numeri haraters o Omit hyphens o Do not begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 49, 69, 70, 78, 79, or 89. o The employer EIN should normally math the EIN under whih tax payments were submitted to the IRS under 941, 943, 944, CT-1 or Shedule H. Employee Name o Enter the name exatly as shown the individual s Soial Seurity Card 4 of 41

8 Employee First Name Employee Middle Initial Employee Last Name Suffix (if shown Soial Seurity Card) o Do not inlude any titles Soial Seurity Number (SSN) o Use the number shown the original /replaement SSN ard o Only numeri haraters o Omit hyphens o May not begin with an 8 or 9 o Do not enter a fititious SSN (for example, , or ). o For valid range numbers, hek the latest list of newly issued Soial Seurity number ranges the Internet at 7. Versis and Printing Notes Ft for data the form: o The printed data the form should use a fixed-pith ft, preferably Courier New (like the IRS PDF versi). o A 9 point ft (for Courier New) seems to work best for most fields, but may require adjustments per field to ensure the max size data is printed within the box. Refer to the IRS PDF doument for a working example. o A ft other than Courier New may also require a different size to fit the data in the appropriate box. The 2010 versi of the form has a few minor hanges from the original 2009 versi: o Some address fields the first page are resized to aommodate the Courier New ft the IRS downloadable PDF versi of the form. o The Foreign Country field now prints the omplete ountry name followed by a dash and the ountry ode (ex. Andorra AN). o The vendor ID should print at the top left of the form, about.5 from the left edge and.5 from the top edge. Print a sample form (IRS versi) with data to see an example of the vendor ID printed. 5 of 41

9 Vendor fasimile forms are required to have a forming barode when printed in order to obtain SSA Approval for 8955-SSA. 6 of 41

10 8. s Data Limitatis Print at 2-D Barode at Text All printable haraters allowed No leading or trailing blanks Amount Mey fields Only haraters 0-9 allowed Right justified, no leading zeros unless 999,999, speified Date Must be a valid date with four positis for the year Numeri Only haraters 0-9 allowed Chekbox Must be apital X or empty Barode is 0 or 1 (Questi 8 is an exepti) SSN Only haraters 0-9 allowed Must tain exatly nine haraters Exepti: Can use haraters FOREIGN May not be left blank. Federal ID Only haraters 0-9 allowed Must tain exatly nine haraters May not be left blank. End of Data Text haraters *EOD* followed by <CR> at the end of eah barode to verify it was read ompletely 09/30/2010 at: mm/dd/yyyy at: mmddyyyy X or leave blank Or FOREIGN 0=Not heked 1=Cheked (Questi 8 is unique. 0 = unheked, 1 = Yes, 2 = No Or FOREIGN NA *EOD* 7 of 41

11 SSA Barode Layout a. Page 1 - Barode 1 (bottom left side) Pos Desripti Box # 1 Header Text 2 T1 NA 2 Developer Code Numeri 4 Notes Print at 2-D Barode at Vendor s NACTP ID or SSA provided ID. This field annot be blank. 3 Jurisditi Numeri 2 US NA 4 Number Numeri 7 Must be 8955SSA NA Versi of this NA 5 Speifiati speifiati used to Text 4 Versi reate this barode. 6 Software Versi Numeri 2 8 of 41 Currently 1.0 Software produt used to reate this barode. Begin with 0 and inrement. Print the top-left of the form, about.5 from the left edge and.5 from the top edge (use approx 6-8 point ft). See IRS printed versi for orret positiing and size) NA 9999

12 Pos Desripti Box # 7 Current Page Number 8 Plan Year Begin Date Part I Text 6 Value must be 1 Date 8 9 Plan Year End Date Part I Date 8 10 Voluntary Filing Indiator 11 Amended Indiator F5558 Appliati Filed Indiator Extensi Automati Indiator Extensi Speial Indiator Extensi Speial Text Part I, A Part I, B Part I, C(a) Part I, C(b) Part I, C() Part I, C(d) Chek Box Chek Box Chek Box Chek Box Chek Box Text 36 Notes Print at 2-D Barode at Valid date formatted mm/dd/yyyy Not past urrent date Barode Omit slashes/dashes Only numeri at mmddyyyy Valid date formatted mm/dd/yyyy Not past urrent date Barode Omit slashes/dashes Only numeri at mmddyyyy 1 0 or 1 in barode 1 0 or 1 in barode 1 0 or 1 in barode 1 0 or 1 in barode 1 0 or 1 in barode NA 1 09/30/2010 at: mm/dd/yyyy 09/30/2010 at: mm/dd/yyyy X or leave blank X or leave blank X or leave blank X or leave blank X or leave blank at: mmddyyyy at: mmddyyyy 0=Not heked 1=Cheked 0=Not heked 1=Cheked 0=Not heked 1=Cheked 0=Not heked 1=Cheked 0=Not heked 1=Cheked 9 of 41

13 Pos Desripti Box # 16 Plan Name 1a 17 Plan Number 18 Spsor Name Spsor Employer Identifiati Number (EIN) Spsor Trade Name 21 Spsor Phe Spsor Care Of name Spsor Street Address 24 Spsor City Name 25 Spsor State 1b 2a 2b 2 2d 2e 2f 2g 2h 40 Numeri 3 Text 70 Federal ID 9 Text 70 Numeri 10 Text 35 Text 35 Text 22 Text 2 Notes Print at 2-D Barode at Only numeri: Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Barode Only numeri Omit dashes & parens Used for U.S. AND foreign addresses Used for U.S. AND foreign addresses U.S. addresses ly Must be a valid state (999) of 41

14 Pos Desripti Box # 26 Spsor Zip Code Spsor Foreign Provine/State Spsor Foreign Country Code Spsor Foreign Routing Code 2i Numeri 9 2j Text 22 2k 2l Text 2 Text End of Data Text 5 *EOD* Notes Print at 2-D Barode at U.S. addresses ly Barode Only numeri Omit dashes For use with foreign addresses For use with foreign addresses Must be a valid ountry ode 3 For use with foreign addresses Full Country Name followed by a dash and the ountry ode (ex. Andorra AN) NA Country Code ly *EOD* 11 of 41

15 b. Page 1 - Barode 2 (bottom right side) Pos Desripti Box # 1 Current Page Number 2 Plan Number 3 Spsor Employer Identifiati Number (EIN) 4 Administrator Name 5 6 Administrator Employer Identifiati Number (EIN) Administrator Care Of Name 1b 2b 3a 3b 3 Text 6 Value must be 1 Numeri 3 Federal ID 9 Text 70 Federal ID 9 Text 35 Notes Print at 2-D Barode at Only numeri: Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Left fill with zeros Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens NA of 41

16 Pos Desripti Box # Administrator Phe Administrator Street Address Administrator City Name 10 Administrator State Administrator Zip Code Administrator Foreign Provine/State Administrator Foreign Country Code Administrator Foreign Routing Code Last Report Admin Name 3d 3e 3f 3g 3h Numeri 10 Text 35 Text 22 Text 2 Numeri 9 3i Text 22 3j 3k 4 Text 2 Text 22 Text 70 Notes Print at 2-D Barode at Barode Only numeri Omit dashes & parens Used for U.S. AND foreign addresses Used for U.S. AND foreign addresses U.S. addresses ly Must be a valid state 2 U.S. addresses ly Barode Only numeri Omit dashes For use with foreign addresses For use with foreign addresses Must be a valid ountry ode 3 For use with foreign addresses (999) Full Country Name followed by a dash and the ountry ode (ex. Andorra AN) Country Code Only 13 of 41

17 Pos Desripti Box # Last Report Admin EIN Last Report Spsor Name Last Report Spsor EIN Last Report Spsor Plan number Separated Partiipants Required SSA a Numeri 9 Text 70 Numeri 9 Numeri 3 Numeri 8 Notes Print at 2-D Barode at Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Only numeri Barode Only numeri Omit ommas, dollar signs, et of 41

18 Pos Desripti Box # Voluntary Separated Partiipants SSA Total Partiipants Reported SSA Individual Statement Indiator 6b 7 8 Numeri 8 Numeri 8 Chek Box 1 Notes Print at 2-D Barode at Barode Only numeri Omit ommas, dollar signs, et. Barode Only numeri Omit ommas, dollar signs, et. 0,1, or 2 in barode Only allow blank, Yes, or No. Do not allow Yes and No to be filled in at the same time X or leave blank 24 End of Data Text 5 *EOD* NA *EOD* 0=Neither blok heked 1=Yes heked 2=No heked 15 of 41

19 . Page 2 - Barode 1 (bottom left side) Pos Desripti Box # 1 Header Text 2 T1 NA 2 Developer Code Numeri 4 Notes Print at 2-D Barode at Vendor s NACTP ID or SSA provided ID. This field annot be blank. 3 Jurisditi Numeri 2 US NA 4 Number Numeri SSA NA Versi of this NA 5 Speifiati speifiati used to Text 5 Versi reate this barode. 6 Software Versi Numeri 2 Currently, the text 1.0 Software produt used to reate this barode. Begin with 0 and inrement. Print the top-left of the form, about.5 from the left edge and.5 from the top edge (use approx 6-8 point ft). See IRS printed versi for orret positiing and size) NA of 41

20 Pos Desripti Box # 7 Current Page Number Text 6 8 Name of Plan i 40 9 Plan Number ii Numeri 3 10 EIN iii Numeri 9 11 Entry Code 1 12 Soial Seurity Number (SSN) 1 13 First Name 1 a b Numeri 9 1 Notes Print at 2-D Barode at 2, 3, 4, et. (the first page 2 will be identified as 2. If additial pages are required, inrement the page number aordingly (i.e. 3, 4, 5, 6, et.) Repeat Name of Plan from Page 1 (seti 1a) Repeat Plan Number from Page 1 (seti 1b) Repeat Spsor EIN from Page 1 (seti 2b) Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN NA Or FOREIGN Or FOREIGN 17 of 41

21 Pos Desripti Box # 14 Middle initial 1 15 Last name of Annuity Code 1 Payment Frequeny Code 1 DB Periodi Payment Amount 1 DC Total Value of Aount Amount 1 d e f g Text 35 Amount 10 Amount 10 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount 9,999,999, ,999,999, of 41

22 Pos Desripti Box # Previous Spsor EIN 1 Previous Spsor Plan Number 1 22 Entry Code 2 23 Soial Seurity Number (SSN) 2 h i a b Numeri 9 Numeri 3 Numeri 9 Notes Print at 2-D Barode at Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Or FOREIGN Or FOREIGN 19 of 41

23 Pos Desripti Box # 24 First Name 2 25 Middle initial 2 26 Last name of Annuity Code 2 Payment Frequeny Code 2 DB Periodi Payment Amount 2 d e f 1 Text 35 Amount 10 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount 9,999,999, of 41

24 Pos Desripti Box # DC Total Value of Aount Amount 2 Previous Spsor EIN 2 Previous Spsor Plan Number 2 33 Entry Code 3 g h i a Amount 10 Numeri 9 Numeri 3 Notes Print at 2-D Barode at Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: Must be 1 harater Only A, B, C, is valid 9,999,999, of 41

25 Pos Desripti Box # 34 Soial Seurity Number (SSN) 3 35 First Name 3 36 Middle initial 3 37 Last name of Annuity Code 3 Payment Frequeny Code 3 b d e Numeri 9 1 Text 35 Notes Print at 2-D Barode at Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Or FOREIGN Or FOREIGN 22 of 41

26 Pos Desripti Box # DB Periodi Payment Amount 3 DC Total Value of Aount Amount 3 Previous Spsor EIN 3 Previous Spsor Plan Number 3 f g h i Amount 10 Amount 10 Numeri 9 Numeri 3 Notes Print at 2-D Barode at Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: ,999,999, ,999,999, of 41

27 Pos Desripti Box # 44 Entry Code 4 45 Soial Seurity Number (SSN) 4 46 First Name 4 47 Middle initial 4 48 Last name 4 49 of Annuity Code 4 a b d Numeri 9 1 Text 35 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Or FOREIGN Or FOREIGN 24 of 41

28 Pos Desripti Box # Payment Frequeny Code 4 DB Periodi Payment Amount 4 DC Total Value of Aount Amount 4 Previous Spsor EIN 4 e f g h Amount 10 Amount 10 Numeri 9 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens 9,999,999, ,999,999, of 41

29 Pos Desripti Box # 54 Previous Spsor Plan Number 4 i Numeri 3 Notes Print at 2-D Barode at Required for Entry Code C Blank for Code A, B, Only numeri: End of Data Text 5 *EOD* NA *EOD* 26 of 41

30 d. Page 2 - Barode 2 (bottom right side) Pos Desripti Box # 1 Current Page Number Text 6 2 Plan Number ii Numeri 3 3 EIN iii Numeri 9 4 Entry Code 5 a Notes Print at 2-D Barode at 2, 3, 4, et. (the first page 2 will be identified as 2. If additial pages are required, inrement the page number aordingly (i.e. 3, 4, 5, 6, et.) Only numeri: Left fill with zeros Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Left fill with zeros Must be 1 harater Only A, B, C, is valid NA of 41

31 Pos Desripti Box # 5 Soial Seurity Number (SSN) 5 6 First Name 5 7 Middle initial 5 8 Last name of Annuity Code 5 Payment Frequeny Code 5 b d e Numeri 9 1 Text 35 Notes Print at 2-D Barode at Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Or FOREIGN Or FOREIGN 28 of 41

32 Pos Desripti Box # DB Periodi Payment Amount 5 DC Total Value of Aount Amount 5 Previous Spsor EIN 5 Previous Spsor Plan Number 5 f g h i Amount 10 Amount 10 Numeri 9 Numeri 3 Notes Print at 2-D Barode at Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Left fill with zeros Required for Entry Code C Blank for Code A, B, Only numeri: Left fill with zeros 9,999,999, ,999,999, of 41

33 Pos Desripti Box # 15 Entry Code 6 16 Soial Seurity Number (SSN) 6 17 First Name 6 18 Middle initial 6 19 Last name 6 20 of Annuity Code 6 a b d Numeri 9 1 Text 35 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Or FOREIGN Or FOREIGN 30 of 41

34 Pos Desripti Box # Payment Frequeny Code 6 DB Periodi Payment Amount 6 DC Total Value of Aount Amount 6 Previous Spsor EIN 6 e f g h Amount 10 Amount 10 Numeri 9 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens 9,999,999, ,999,999, of 41

35 Pos Desripti Box # 25 Previous Spsor Plan Number 6 26 Entry Code 7 27 Soial Seurity Number (SSN) 7 28 First Name 7 29 Middle initial 7 30 Last name 7 i a b Numeri 3 Numeri 9 1 Text 35 Notes Print at 2-D Barode at Required for Entry Code C Blank for Code A, B, Only numeri: Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Or FOREIGN Or FOREIGN 32 of 41

36 Pos Desripti Box # of Annuity Code 7 Payment Frequeny Code 7 DB Periodi Payment Amount 7 DC Total Value of Aount Amount 7 d e f g Amount 10 Amount 10 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount 9,999,999, ,999,999, of 41

37 Pos Desripti Box # Previous Spsor EIN 7 Previous Spsor Plan Number 7 37 Entry Code 8 38 Soial Seurity Number (SSN) 8 h i a b Numeri 9 Numeri 3 Numeri 9 Notes Print at 2-D Barode at Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Or FOREIGN Or FOREIGN 34 of 41

38 Pos Desripti Box # 39 First Name 8 40 Middle initial 8 41 Last name of Annuity Code 8 Payment Frequeny Code 8 DB Periodi Payment Amount 8 d e f 1 Text 35 Amount 10 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount 9,999,999, of 41

39 Pos Desripti Box # DC Total Value of Aount Amount 8 Previous Spsor EIN 8 Previous Spsor Plan Number 8 48 Entry Code 9 g h i a Amount 10 Numeri 9 Numeri 3 Notes Print at 2-D Barode at Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: Must be 1 harater Only A, B, C, is valid 9,999,999, of 41

40 Pos Desripti Box # 49 Soial Seurity Number (SSN) 9 50 First Name 9 51 Middle initial 9 52 Last name of Annuity Code 9 Payment Frequeny Code 9 b d e Numeri 9 1 Text 35 Notes Print at 2-D Barode at Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Must be 1 harater Only A, B, C, D, E, or M is valid Or FOREIGN Or FOREIGN 37 of 41

41 Pos Desripti Box # DB Periodi Payment Amount 9 DC Total Value of Aount Amount 9 Previous Spsor EIN 9 Previous Spsor Plan Number 9 f g h i Amount 10 Amount 10 Numeri 9 Numeri 3 Notes Print at 2-D Barode at Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens Required for Entry Code C Blank for Code A, B, Only numeri: ,999,999, ,999,999, of 41

42 Pos Desripti Box # 59 Entry Code Soial Seurity Number (SSN) First Name Middle initial Last name of Annuity Code 10 a b d Numeri 9 1 Text 35 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, is valid Only numeri haraters* Omit dashes Must be 9 positis All zeroes for any segment is not valid Cannot start with 8 or 9 First 3 positis annot be 666 *Exepti may tain the word FOREIGN Must be 1 harater Only A, B, C, D, E, F, G, or M is valid Or FOREIGN Or FOREIGN 39 of 41

43 Pos Desripti Box # Payment Frequeny Code 10 DB Periodi Payment Amount 10 DC Total Value of Aount Amount 10 Previous Spsor EIN 10 e f g h Amount 10 Amount 10 Numeri 9 Notes Print at 2-D Barode at Must be 1 harater Only A, B, C, D, E, or M is valid Only numeri haraters Omit Deimals Round to nearest whole dollar amount Only numeri haraters Omit Deimals Round to nearest whole dollar amount Required for Entry Code C Blank for Code A, B, Must NOT begin with 00, 07, 08, 09, 17, 18, 19, 28, 29, 69, 70, 78, 79, or 89 Barode Only numeri Omit hyphens 9,999,999, ,999,999, of 41

44 Pos Desripti Box # 69 Previous Spsor Plan Number 10 i Numeri 3 Notes Print at 2-D Barode at Required for Entry Code C Blank for Code A, B, Only numeri: End of Data Text 5 *EOD* NA *EOD* 2 Valid 2-harater State an be found at: See Part A. Seti 7. State Abbreviatis Do not use Military state addresses 3 Valid 2-harater Country an be found at: See Part A. Seti 8. Foreign Country These are the FIPS ountry odes 41 of 41