Federal housing law
0119 Form 15091 (PDF)
Federal housing law as enacted — verbatim and citable.
- Edition
- 2026-10-03
- Last updated
- 2026-10-04
- Jurisdiction
- United States
Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15091.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).
Form 15091¶
(January 2019)
Department of the Treasury - Internal Revenue Service
Benefit Assurance¶
Date Employer Identification Number (EIN) DLN
Address Person to contact Contact telephone number
Plan name Plan number
Complete and return this form to the Technical or Review Staff at the address shown below.
Date of termination
Date(s) excess assets received Amount
Date(s) guaranteed annuity contracts purchased Amount
Date(s) lump sum distributions paid Amount
I certify that the above plan's liabilities to all plan participants have been satisfied by the purchase of guaranteed annuity contracts or the payment of lump sum distributions.
Signature Title Date
Mail the information requested in this form to the following address: IRS - Tax Exempt and Government Entities
CPC:C&CA Referrals Group Mail Stop 4910DAL 1100 Commerce Street Dallas, TX 75242-1027
Catalog Number 71905U www.irs.gov Form 15091 (Rev. 1-2019)