Plan Name:_____________________________
EIN:
Plan #:
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 § 401(a)(17) failure, and the total required
contribution (before adjusting for earnings) for each plan year in which the failure occurred:
Fraction Used to Determine
Total Required Contribution (before
Plan Year
the Additional Amount
adjusting for earnings)
Allocated
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:
Former employees affected by the failure (check one):
There are no former employees affected by the failure.
Affected former employees will be contacted and contributions will be made to the plan on their
behalf. To the extent that an affected former employee cannot be located following a mailing to
the employee’s last known address, the Plan Sponsor will take reasonable actions to locate that
employee. Such actions include the use of the Internal Revenue Service Letter Forwarding
Program (see Rev. Proc. 94-22, 1994-1 C.B. 608) or the Social Security Administration Employer
Reporting Service. After such actions are taken, if an affected employee is not found but is
subsequently located on a later date, the Plan Sponsor will make corrective contributions on behalf
of the affected employee at that time.