Form 14568-I (Rev. 9-2017)
www.irs.govCatalog Number 66156F
For Paperwork Reduction Act information see current EPCRS Revenue Procedure.
Form 14568-I
(September 2017)
Department of the Treasury - Internal Revenue Service
Model VCP Compliance Statement - Schedule 9:
Limited Safe Harbor Correction by Plan Amendment
OMB Number
1545-1673
Include the plan name, Applicant’s EIN and plan number on each page of the compliance statement.
Plan name
EIN Plan number
Section I - Identification of Failure(s) and Proposed Method(s) of Correction
The following failure(s) to comply with the Internal Revenue Code (IRC) occurred with respect to the plan identified above
(check failure(s) that apply)
A. IRC Section 401(a)(17) Failure in a Defined Contribution Plan (check as applicable)
Contributions
Forfeitures
were allocated on the basis of compensation in excess of the limit under IRC Section 401(a)(17) as provided below
Enter the plan years in which the failure occurred, the amount of the allocations in excess of IRC Section 401(a)(17)
made for each plan year (adjust for earnings), and the number of participants affected by the failure for each plan
year:
Plan Year
Amounts Allocated in Excess of
IRC Section 401(a)(17)
Number of Participants Affected
Description of Proposed Method of Correction
An additional amount has been (or will be) contributed to the plan on behalf of each of the employees who received
an allocation for the year of the failure (excluding each employee for whom there was a IRC Section 401(a)(17)
failure). The amount contributed for an employee is equal to the employee's plan compensation for the year of the
failure multiplied by a fraction, the numerator of which is the improperly allocated amount made on behalf of the
employee with the largest improperly allocated amount, and the denominator of which is the limit under IRC Section
401(a)(17) applicable to the year of the failure. In addition, the plan will be retroactively amended by the plan sponsor
to reflect the increased contribution and allocation percentages for the plan’s participants.
Enter the plan years in which the failure occurred, the fraction used to determine the additional amount allocated to
employees other than those for whom there was a IRC Section 401(a)(17) failure, and the total required contribution
(before adjusting for earnings) for each plan year in which the failure occurred:
Plan Year
Fraction Used to Determine the
Additional Amount Allocated
Total Required Contribution
(Before Adjusting for Earnings)
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Form 14568-I (Rev. 9-2017)
www.irs.govCatalog Number 66156F
Plan numberEIN
Plan name
The resulting additional amount will be adjusted for earnings from the end of the plan year in which the failure
occurred through the date of the corrective contribution. The method for determining the earnings adjustment is as
follows (Attach additional pages as needed. Label the attachment “Section IA of Form 14568-I, Description of the
Proposed Method of Correction-Earnings” and include the plan name, Applicant’s EIN and plan number at the top of
each page).
Former employees affected by the failure (check one)
There are no former employees affected by the failure.
Affected former employees (or if deceased, their estate or known beneficiary) will be contacted and contributions
will be made to the plan on their behalf. To the extent that an affected former employee or beneficiary cannot be
located following a mailing to the last known address, the plan sponsor will take the actions specified below to
locate that employee or beneficiary.
After such actions are taken, if an affected employee or beneficiary is not found but is located at a later date, the
plan sponsor will make corrective contributions on behalf of the affected employee at that time.
B. Hardship Distribution Failure
Hardship distributions were made to participants under the plan even though the written terms of the plan did not
provide for any hardship distributions. All plan participants were entitled to request hardship distributions, and all
requests were evaluated in accordance with uniform eligibility standards, as described below.
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Form 14568-I (Rev. 9-2017)
www.irs.govCatalog Number 66156F
Plan numberEIN
Plan name
Enter the plan years in which the failure occurred, the number of hardship distributions made for each plan year, and
the number and amount of distributions made to Highly Compensated Employees (HCEs) and Nonhighly
Compensated Employees (NHCEs) respectively, affected by the failure for each plan year.
Plan Year
Number of Hardship
Distributions Made
During the Plan
Year
Number of Hardship
Distributions Made
to NHCEs
Amount of
Distributions
Number of Hardship
Distributions Made
to HCEs
Amount of
Distributions
Description of the Proposed Method of Correction
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the
hardship distributions that were made available. The effective date of the corrective amendment is
.
C. Plan Loan Failure
Plan loans were made to participants under the plan even though the written terms of the plan did not provide for any
participant loans. All plan participants were entitled to request plan loans under uniform standards of eligibility and all
plan loans made satisfied the requirements of IRC Section 72(p).
Enter the plan years in which the failure occurred, the number of participant plan loans made for each plan year, and
the number and amount of plan loans made to HCEs and NHCEs respectively, affected by the failure for each plan
year.
Plan Year
Number of Plan
Loans Made During
the Plan Year
Number of Plan
Loans Made to
NHCEs
Amount of Plan
Loans
Number of Plan
Loans Made to
HCEs
Amount of
Plan Loans
Description of the Proposed Method of Correction
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the plan
loans that were made available. The effective date of the corrective amendment is
.
D. Early Inclusion of Otherwise Eligible Employee Failure
Employees: (check applicable boxes)
Who had not satisfied the plan’s minimum age or service requirements were treated as eligible participants on a
date prior to their being eligible under the plan and were entitled to the same benefits under the plan to which they
would have been entitled had they completed the minimum age or service requirements of the plan.
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Form 14568-I (Rev. 9-2017)
www.irs.govCatalog Number 66156F
Plan numberEIN
Plan name
Who had completed the plan’s minimum age or service requirements were treated as eligible participants prior to
the applicable plan entry date and were entitled to the same benefits under the plan to which they would have
been entitled had they entered the plan timely.
The plan’s minimum age or service requirements and plan entry date, as applicable, for the years of the failure were
Enter the plan years in which the failure occurred and the number of participants affected by the failure, broken down
by type of employee (HCE or NHCE) respectively, for each plan year.
Plan Year
Number of NHCEs Affected by
the Failure During the Plan Year
Number of HCEs Affected by
the Failure During the Plan Year
Description of the Proposed Correction Method
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the
inclusion of the ineligible employees. The effective date of the corrective amendment is
.
Section II - Change in Administrative Procedures
Include an explanation of how and why the failures arose and a description of the measures that will be (or have
been) implemented to ensure that the same failures will not recur.
Page 5
Form 14568-I (Rev. 9-2017)
www.irs.govCatalog Number 66156F
Plan numberEIN
Plan name
Section III - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor
encloses the following with this submission:
Copies of all amendments used to correct the failure(s), either as adopted or in proposed form. (required)
A copy of the plan document in effect prior to any of the amendments used to correct the failure(s). (required)
For an IRC Section 401(a)(17) failure in a defined contribution plan, specific calculations for each affected
employee or a representative sample of affected employees. (The sample calculations must be sufficient to
demonstrate each aspect of the correction method proposed. For example, the determination of the fraction used to
determine the additional amount to be allocated to each employee (other than those for whom there was an IRC
Section 401(a)(17) failure) must be demonstrated.
For Early Inclusion of Otherwise Eligible Employee Failure, submit a demonstration or analysis that
o Establishes that the corrective amendment is non-discriminatory under IRC Section 401(a)(4). Only include this
item if HCEs benefited from the corrective plan amendment.
o Proves the early inclusion of otherwise eligible employees did not result in an IRC Section 411(d)(6) cutback for
the plan’s other participants.
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