Date, EIN and DLN
The top row holds the date, the employer identification number and a document locator number (DLN).
15091
Benefit Assurance
- Agency
- IRS
- Revision
- Rev. 1-2019
- Fillable fields
- 18
- Pages
- 1
- Official source
- IRS form page
- Checked
- October 21, 2026
Form 15091: Benefit Assurance
Form 15091, Benefit Assurance, is a one-page IRS form about a plan that has terminated. It asks for the plan's name and number, the employer identification number (EIN), the date of termination, and the dates and amounts of excess assets received, guaranteed annuity contracts purchased and lump sum distributions paid.
The signer certifies that the plan's liabilities to all plan participants have been satisfied by the purchase of guaranteed annuity contracts or the payment of lump sum distributions. The form says to complete and return it to the Technical or Review Staff at the IRS Tax Exempt and Government Entities address printed on it.
The PDF has no separate instructions. You can fill out Form 15091 free in your browser on this page and download it without an account.
What's on Form 15091
Contact and plan
The address, person to contact, contact telephone number, plan name and plan number.
Date of termination
A single field for the date the plan terminated.
Dates and amounts
Three rows, each with dates and an amount: excess assets received, guaranteed annuity contracts purchased and lump sum distributions paid.
Certification
A statement that the plan's liabilities to all plan participants have been satisfied, with signature, title and date.
How to fill out Form 15091
- 1
Top row
Enter the date, the EIN and the DLN.
- 2
Contact and plan
Enter the address, the person to contact and their telephone number, then the plan name and plan number.
- 3
Termination date
Enter the date of termination of the plan.
- 4
Dates and amounts
For each row that applies, enter the dates excess assets were received, guaranteed annuity contracts were purchased or lump sum distributions were paid, and the amount.
- 5
Sign and mail
Sign the certification, enter a title and date, and mail the form to the address printed at the bottom.
Why fill Form 15091 on indox
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Where to send it
Mailing address
The form prints: IRS - Tax Exempt and Government Entities, CPC:C&CA Referrals Group, Mail Stop 4910DAL, 1100 Commerce Street, Dallas, TX 75242-1027.
Who receives it
The form says to complete and return it to the Technical or Review Staff at that address.
What is certified
The form says the signer certifies that the plan's liabilities to all plan participants have been satisfied by the purchase of guaranteed annuity contracts or the payment of lump sum distributions.
Deadline
The form prints no deadline and has no separate instructions.
Related forms
Who fills out Form 15091?
The form does not name the role of the person who completes it. It asks for a plan's details, a contact person and a signature with a title.
Official sources and the blank
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Questions about Form 15091
What is Form 15091?
It is the IRS Benefit Assurance form. It records how a terminated plan's liabilities to all plan participants were satisfied and carries a signed certification.
Where is Form 15091 mailed?
To IRS - Tax Exempt and Government Entities, CPC:C&CA Referrals Group, Mail Stop 4910DAL, 1100 Commerce Street, Dallas, TX 75242-1027, as printed on the form.
What amounts does it ask for?
Dates and amounts for excess assets received, guaranteed annuity contracts purchased and lump sum distributions paid.
Does Form 15091 have instructions?
No separate instructions are printed. The form only says to complete and return it to the Technical or Review Staff at the address shown.