Appendix D - Vcp Submission - Internal Revenue Service
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4APPENDIX D
VCP SUBMISSION
Plan Name: __________________________________ EIN: _______________ Plan #: _____
(Please include the plan name, EIN, and plan number information on each page of the submission.)
PART 1 – PLAN INFORMATION
1. APPLICANT’S NAME _______________________________________________________________________
2. APPLICANT’S ADDRESS
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. APPLICANT’S TELEPHONE NO. __________________ 4. FAX NO. ________________________________
(optional)
(optional)
5. APPLICANT’S EIN ________________________ 6. PLAN NO. _____________________________________
(do not use Social Security Number)
7. PLAN NAME _______________________________________________________________________________
8. TYPE OF SUBMISSION
REGULAR SUBMISSION
REGULAR SUBMISSION - ANONYMOUS
REGULAR SUBMISSION – MULTI-EMPLOYER PLAN
REGULAR SUBMISSION – MULTIPLE EMPLOYER PLAN
GROUP SUBMISSION
9. TYPE OF PLAN (CHECK ONE ONLY):
01
10
PROFIT SHARING
GOV'T. DEFINED BENEFIT - 414(d)
02
20
401(k)
GOV'T. DEFINED CONTRIB. - 414(d)
03
11
MONEY PURCHASE
SEP
04
12
DEFINED BENEFIT
SARSEP
05
13
ESOP
SIMPLE
06
14
TARGET BENEFIT
STOCK BONUS
07
15
403(b)
KSOP
09
CASH BALANCE
OTHER (specify):
10. DATE (month and day) ON WHICH PLAN YEAR ENDS __________________________________________
11. NUMBER OF PARTICIPANTS IN THE PLAN AS PROVIDED ON THE MOST RECENTLY FILED FORM
5500 SERIES (See Rev. Proc. 2008-50, section 12.07.) (or, if not filed, or not required to file, the most recent data
available to the Plan Sponsor): ____________________________________________________________________
12. ASSETS IN THE PLAN AS PROVIDED ON THE MOST RECENTLY FILED FORM 5500 SERIES
(ROUND TO NEAREST DOLLAR) (See Rev. Proc. 2008-50, section 12.07.) (or, if not filed, or not required to file,
the most recent data available to the Plan Sponsor):: $ _________________________________________________
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