Appendix F, Schedule 8 Failure To Pay Required Minimum Distributions Timely Under 401(A)(9) Page 2

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Plan Name:_____________________________
EIN:
Plan #:
PART III. REQUEST FOR RELIEF
A.
The Applicant requests relief with regard to excise taxes under § 4974
Yes No
At least one affected participant is either an owner-employee (see § 401(c)(3)) or, if the Plan
Sponsor is a corporation, a 10 percent owner of such corporation.
If “Yes,” the Applicant submits the following explanation for its request for relief from the § 4974 excise tax:
PART IV. CHANGE IN ADMINISTRATIVE PROCEDURES
Please include an explanation of how and why the failures arose and a description of the measures that will be
implemented to ensure that the same failures will not occur.
PART V. ENCLOSURES
In addition to the applicable enclosures listed on Appendix F, the Plan Sponsor encloses the following with this
submission:
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 a defined benefit
plan, these specific calculations must illustrate the interest rate used to represent the loss of the use of the missed
required minimum distributions.)
2

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