Plan Name: _____________________________________________
EIN: _______________
Plan #: _____
an abusive tax avoidance transaction. The compliance statement should not be construed as affecting the rights of
any party under any other law, including Title I of the Employee Retirement Income Security Act of 1974.
This compliance statement is conditioned on (1) there being no misstatement or omission of material facts in
connection with the submission and (2) the completion of all corrections described in the applicable schedule(s) to
this Appendix F submission within one hundred fifty (150) days of the date of the compliance statement.
In addition: (paragraph applies only if checked by the Service)
For failure(s) described in Schedule 1 of Appendix F, the Service will treat the amendments as if they had
been adopted timely for the purpose of making available the extended remedial amendment period set forth
in Revenue Procedure 2007-44, 2007-28 I.R.B. 54, or its successors. However, this compliance statement
does not constitute a determination as to whether any such plan amendment, as drafted, complies with the
applicable change in qualification requirements.
For failure(s) described in Schedule 3 of Appendix F, the Service will not pursue the following:
Excise tax under § 4972.
Excise tax under § 4979.
For failure(s) described in Schedule 4 of Appendix F, the Service will not pursue excise tax under § 4972.
For loan failure(s) described in section __________ of Schedule 5 of Appendix F, the Service will not
require the deemed distributions to be reported on Form 1099-R with respect to the participant(s) affected
by the failure(s). The repayments made pursuant to the correction of such loan(s) will not result in an
affected participant having additional basis in the plan for the purpose of determining the tax treatment of
subsequent distributions from the plan to such participant(s).
For loan failure(s) described in section __________ of Schedule 5 of Appendix F, the Service will require
the deemed distributions to be reported on Form 1099-R with respect to the participant(s) affected by the
failure(s). However, the plan will be permitted to report deemed distributions on Form 1099-R in the year
of correction instead of the year of the failure.
For minimum distribution failure(s) described in Schedule 8 of Appendix F, the Service will waive the
excise tax under § 4974.
Approved: _______________________________
Martin L. Pippins, Manager
Employee Plans Voluntary Compliance
Tax Exempt and Government Entities Division
Date: _______________________________
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