Appendix F - Streamlined Vcp Submission - Internal Revenue Service Page 2
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4Plan Name: _____________________________________________
EIN: _______________
Plan #: _____
If the Applicant is being represented by someone in connection with this matter or wishes to authorize
someone to receive information from us in connection with this matter, submit a completed Form 2848 or
Form 8821 and complete items 13 through 18.
13. NAME OF APPLICANT’S REPRESENTATIVE __________________________________________________
14. NAME OF REPRESENTATIVE’S FIRM NAME _________________________________________________
15. REPRESENTATIVE’S ADDRESS: ____________________________________________________________
16. REPRESENTATIVE’S PHONE NO. _________________
17. FAX NO. ___________________________
18. REPRESENTATIVE’S E-MAIL ADDRESS ____________________________________________________
(optional)
PART II. APPLICANT’S ENCLOSURES
The Applicant encloses the following documents with this submission:
VCP fee of $_________ made payable to the U.S. Treasury (required). (If the fee is determined on the
basis of treating Transferred Assets as a separate plan, pursuant to section 12.07 of Rev. Proc. 2008-50,
please enclose a description of the related employer transaction, including the date of the employer
transaction and the date the assets were transferred to the plan.)
A written request if the application is made for a terminating Orphan Plan and the Applicant is applying for
a waiver of the VCP fee.
Power of Attorney (Form 2848) or Tax Information Authorization (Form 8821), if applicable.
If the plan is being considered for an unrelated determination letter application, a statement to that effect.
Appendix E (optional)
Completed Appendix F schedule(s). (Check the schedules that apply)
Schedule 1 - Interim and Certain Discretionary Nonamender Failures
Schedule 2 - Nonamender Failures (other than those to which Schedule 1 applies)
Schedule 3 - SEPs and SARSEPs
Schedule 4 - SIMPLE IRAs
Schedule 5 - Plan Loan Failures
Schedule 6 - Employer Eligibility Failure
Schedule 7 - Failure to Distribute Elective Deferrals in Excess of the § 402(g) Limit
Schedule 8 - Failure to Pay Required Minimum Distributions Timely under § 401(a)(9)
Schedule 9 - Correction by Plan Amendment (in accordance with Appendix B)
Information required by each schedule, as set forth in each applicable Part entitled “Enclosures.”.
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