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Official form guide
Form 15091: Benefit Assurance
IRS Form 15091 is the Benefit Assurance form used to certify that a plan’s liabilities have been satisfied by guaranteed annuity contracts or lump‑sum payments. The form is dated January 2019 (Rev. 1‑2019).
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IRS Form 15091 - Benefit Assurance
IRS Form 15091 is the Benefit Assurance form used to certify that a plan’s liabilities have been satisfied by guaranteed annuity contracts or lump‑sum payments. The form is dated January 2019 (Rev. 1‑2019).
Risk Radar
Scan points- 1Failing to sign the certification makes the filing invalid.
- 2Omitting the Employer Identification Number (EIN) leaves the filing incomplete.
- 3Leaving the Plan number blank prevents proper plan identification.
- 4Not providing the Date of termination fails to record the plan’s closure date.
- 5Failing to list dates and amounts of excess assets received omits required financial details.
Plain English
This form tells the IRS that a retirement plan has paid off all participant obligations either by buying guaranteed annuities or by making lump‑sum payouts. The plan sponsor fills out the details and signs the certification.
Submission Date
- Filing date: 2024-12-04 22:10:58
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- Use this form when the plan’s liabilities to all participants have been satisfied by the purchase of guaranteed annuity contracts or by lump‑sum distributions.
Form selector
Use this form or another form?
Plan termination with guaranteed annuity purchase
Certifies liability satisfaction via annuity contracts
✓ Verify annuity contract details before proceeding
Plan termination with lump‑sum distribution
Certifies liability satisfaction via lump‑sum payments
✓ Verify lump‑sum amounts before proceeding
Plan termination without liability satisfaction
Not appropriate; the form requires liability satisfaction
✓ Confirm liabilities are satisfied before using this form
Deadline or filing window
Not stated in the official source.
Checklist
What you need before filling it out
Employer Identification Number (EIN)
Employer’s EIN · Form header
Plan name
Official plan name · Form field "Plan name"
Date of termination
Effective termination date · Form field "Date of termination"
Amount of guaranteed annuity contracts purchased
Contract purchase amount · Form field "Amount" next to guaranteed annuity contracts
Signature
Authorized signature of plan representative · Signature line
Before you submit
- 1Verify the EIN is entered correctly
- 2Confirm the plan name and plan number match official records
- 3Check that the termination date is accurate
- 4Enter all required dates for excess assets, annuity purchases, and lump‑sum distributions
- 5Enter the corresponding amounts for each date entry
- 6Sign, print title, and date the certification line
- 7Mail the completed form to the address listed on the form
How to file this form
- 1Complete all required fields on Form 15091
- 2Review entries for accuracy and completeness
- 3Sign, title, and date the certification statement
- 4Mail the form to IRS - Tax Exempt and Government Entities CPC:C&CA Referrals Group, Mail Stop 4910DAL, 1100 Commerce Street, Dallas, TX 75242-1027
- 5Retain a copy of the signed form for your records
Known limitations
- 1You must verify the form edition reads Rev. 1‑2019 (January 2019); older revisions may lack required fields or instructions.
- 2You should confirm that the mailing address matches IRS – Tax Exempt and Government Entities CPC:C&CA Referrals Group Mail Stop 4910DAL, 1100 Commerce Street, Dallas, TX 75242‑1027.
- 3You need to ensure a signature, printed title, and date appear on the certification line; missing elements invalidate the filing.
- 4You must note that the official source does not list any filing fee; verify on the IRS website whether a fee applies.
- 5You should re‑check for any updates before submission, as IRS forms often receive minor revisions after the listed January 2019 date.
Field map
Compact field-by-field guide
General Info
2 items
Full legal name and taxpayer identification number (SSN or EIN).
Current mailing address.
Details
2 items
Complete all applicable sections of this form according to the official IRS instructions.
Enter the relevant dollar amount if this form involves tax calculation.
Certification
1 items
Read and acknowledge any certifications required by this form.
Signatures
1 items
Sign and date. Unsigned forms cannot be processed.
Almost done reviewing the fields?
Fillable formOpen in Editor->Form 15091 is dated January 2019 with revision 1‑2019; the source does not indicate a later version or changes.
What changed or needs a fresh check
- Edition date — confirm the form shows Rev. 1‑2019 (January 2019)
- Fee — Not stated in the official source
- Mailing address — confirm the address is IRS - Tax Exempt and Government Entities CPC:C&CA Referrals Group Mail Stop 4910DAL 1100 Commerce Street Dallas, TX 75242-1027
- Signature — confirm a signature, title, and date appear on the certification line
Quick Facts
Downloads
After you file
- 1Keep the signed copy in the plan’s permanent file
- 2Monitor for any follow‑up correspondence from the IRS
- 3If an error is discovered, submit a corrected Form 15091
Sources
- SRCForm p.1 — revision noted as Rev. 1‑2019 (January 2019)
- SRCForm p.1 — mailing address listed as IRS - Tax Exempt and Government Entities CPC:C&CA Referrals Group Mail Stop 4910DAL 1100 Commerce Street Dallas, TX 75242-1027
- SRCForm p.1 — fields include EIN, DLN, address, contact person, telephone, plan name, plan number, termination date, dates and amounts for assets, annuity contracts, lump‑sum distributions
- SRCForm p.1 — certification statement requires signature, title, and date
- SRCForm p.1 — instruction to complete and return to Technical or Review Staff at the address shown
- SRCNot stated in the official source — verify on the agency site
Common confusion points
Where do I mail the completed form?
The form lists a specific IRS address at the bottom, which may be overlooked.
→ Verify the mailing address matches 'IRS - Tax Exempt and Government Entities CPC:C&CA Referrals Group Mail Stop 4910DAL 1100 Commerce Street Dallas, TX 75242-1027'.
Which date should I enter in the form?
Multiple date fields (termination, excess assets, annuity purchase, lump‑sum distribution) can cause uncertainty.
→ Use the date that corresponds exactly to each labeled event on the form.
Is the Employer Identification Number required?
The form includes an EIN field, but its necessity isn’t explained in the text.
→ Provide the plan’s EIN in the EIN field as shown on the form.
Do I need to supply a contact telephone number?
A contact telephone number field appears without guidance.
→ Enter a valid telephone number where the IRS can reach the contact person.
What information belongs in the Plan name and Plan number fields?
The form lists separate fields for plan identification, which may be confused with other identifiers.
→ Enter the official plan name and its assigned plan number exactly as recorded.
Is a signature, title, and date required?
The certification section includes signature, title, and date lines.
→ Sign the form, print your title, and date it to complete the certification.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Form 15091 — submit a corrected form to address errors
Questions about IRS Form 15091
What is IRS Form 15091 used for?
This form tells the IRS that a retirement plan has paid off all participant obligations either by buying guaranteed annuities or by making lump‑sum payouts. The plan sponsor fills out the details and signs the certification.
What information does IRS Form 15091 require?
The form collects the Date, Employer Identification Number (EIN), DLN, address, contact person and telephone, plan name and number, date of termination, dates and amounts of excess assets received, guaranteed annuity contracts purchased, lump‑sum distributions paid, and a certification signature.
Where do I file IRS Form 15091?
Mail the completed form to IRS – Tax Exempt and Government Entities, CPC:C&CA Referrals Group, Mail Stop 4910DAL, 1100 Commerce Street, Dallas, TX 75242‑1027.
How do I complete IRS Form 15091?
Complete the form by entering the required identifiers, plan details, and dates of termination, asset receipts, annuity purchases, and lump‑sum payouts. Certify that all liabilities are satisfied, then sign, print your title, and date the form. Mail the signed form to the Technical or Review Staff address provided on the form.
Where do I mail the completed form?
The form lists a specific IRS address at the bottom, which may be overlooked. Verify the mailing address matches 'IRS - Tax Exempt and Government Entities CPC:C&CA Referrals Group Mail Stop 4910DAL 1100 Commerce Street Dallas, TX 75242-1027'.
Which date should I enter in the form?
Multiple date fields (termination, excess assets, annuity purchase, lump‑sum distribution) can cause uncertainty. Use the date that corresponds exactly to each labeled event on the form.
Is the Employer Identification Number required?
The form includes an EIN field, but its necessity isn’t explained in the text. Provide the plan’s EIN in the EIN field as shown on the form.
Do I need to supply a contact telephone number?
A contact telephone number field appears without guidance. Enter a valid telephone number where the IRS can reach the contact person.
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