Fillable Appendix F - Streamlined Vcp Submission - Internal Revenue Service (Page 3 of 4) in pdf

Plan Name: _____________________________________________

EIN: _______________

Plan #: _____

PART III. APPLICANT’S REPRESENTATIONS

Under Examination

To the best of my knowledge:

The subject plan is not currently under examination of either an Employee Plans Form 5500 series return or

other Employee Plans examination,

The Plan Sponsor is not under an Exempt Organizations examination (that is, an examination of a Form

990 series return or other Exempt Organizations examination),

Neither the Plan Sponsor nor any of its representatives has received verbal or written notification from the

Tax Exempt and Government Entities Division of the Internal Revenue Service (“Service”) of an

impending examination or of any impending referral for such examination nor is the plan in Appeals or

litigation for any issues raised in such an examination, and

The subject plan is not currently under investigation by the Criminal Investigation Division of the Internal

Revenue Service.

Abusive tax avoidance transaction (check box that applies)

Neither the plan nor the Plan Sponsor has been a party to an abusive tax avoidance transaction as

defined in section 4.13(2) of Rev. Proc. 2008-50.

The plan or the Plan Sponsor has been a party to an abusive tax avoidance transaction. Details of

the transaction(s) are provided in a separate statement which has been included with the

submission.

Compliance Fee

The Applicant will neither attempt to amortize, deduct, or recover from the Internal Revenue Service any

compliance fee paid in connection with this compliance statement nor receive any Federal tax benefit on

account of payment of such compliance fee.

Penalties of Perjury

Under penalties of perjury, I declare that I have examined this submission, including accompanying

documents and representations. To the best of my knowledge and belief, the facts and information

presented in support of this submission are true, correct, and complete.

Signed: _________________________________

Date: ____________________

Name (printed): _________________________________

Title: __________________________________________

PART IV: ENFORCEMENT RESOLUTION (to be completed by IRS only)

The Internal Revenue Service will not pursue the sanction of revoking the tax-favored status of the plan under §§

401(a), 403(b), 408(k), or 408(p) of the Internal Revenue Code on account of the failure(s) described in the

schedules submitted pursuant to this Appendix F. This compliance statement considers only the acceptability of the

correction method(s) and the revision(s) of administrative procedures described in the schedules submitted pursuant

to this Appendix F submission and does not express an opinion as to the accuracy or acceptability of any

calculations or other material submitted with the application. In no event may this compliance statement be relied

on for the purpose of concluding that the plan or Plan Sponsor (as defined in Rev. Proc. 2008-50) was not a party to

Appendix F - Streamlined Vcp Submission - Internal Revenue Service Page 3