Catalog Number 67750H
14704 (5-2015)
Form 14704
(May 2015)
Department of the Treasury - Internal Revenue Service
Transmittal Schedule – Form 5500-EZ
Delinquent Filer Penalty Relief Program
(Revenue Procedure 2015-32)
(Attach to Oldest Delinquent Return in this Submission)
OMB Number
1. Applicant’s name (plan sponsor or plan administrator)
2. Applicant's street address
3. City or town, state and zip code (include foreign country name, province/county and zip code, if applicable)
4. Applicant’s Employer Identification Number (do not use a Social Security Number) 5. Applicant’s telephone number
6. Plan number 7. Plan name
8. Indicate the last day of the plan year for each delinquent return included in this submission (enter MM/DD/YY)
9. Check the applicable box below for the amount of payment
Number of Delinquent Returns in this Submission Amount of Payment (choose one)
(a) One delinquent return $500
(b) Two delinquent returns $1,000
(c) Three or more delinquent returns $1,500