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

Plan Name:_____________________________

EIN:

Plan #:

With respect to failure(s) #________, that a deemed distribution corrected pursuant to this VCP

submission not be required to be reported on Form 1099-R and that repayments made by such

correction not result in the affected participant having additional basis in the plan for purposes of

determining the tax treatment of subsequent distributions from the plan.

With respect to failure(s) #________, that a deemed distribution be reported on Form 1099-R with

respect to affected participant(s) for the year of correction instead of the year of the failure.

PART VI. APPLICANT’S REPRESENTATIONS

(Note: Since the representations include the penalty of perjury statement, the representations under Part VI of this

Appendix D must be signed by the Plan Sponsor, not the plan representative.)

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 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: _______________________________________

Appendix D - Vcp Submission - Internal Revenue Service Page 3