Form 14568-I - Model Vcp Compliance Statement Schedule 9 Limited Safe Harbor Correction By Plan Amendment Page 3

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Plan name
EIN
Plan number
Enter the plan years in which the failure occurred, the number of hardship distributions made for each plan year, and
the number and amount of distributions made to Highly Compensated Employees (HCEs) and Nonhighly
Compensated Employees (NHCEs) respectively, affected by the failure for each plan year.
Number of Hardship
Number of Hardship
Number of Hardship
Distributions Made
Amount of
Amount of
Plan Year
Distributions Made
Distributions Made
During the Plan
Distributions
Distributions
to NHCEs
to HCEs
Year
Description of the Proposed Method of Correction
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the
hardship distributions that were made available. The effective date of the corrective amendment is
.
C. Plan Loan Failure
Plan loans were made to participants under the plan even though the written terms of the plan did not provide for any
participant loans. All plan participants were entitled to request plan loans under uniform standards of eligibility and all
plan loans made satisfied the requirements of IRC Section 72(p).
Enter the plan years in which the failure occurred, the number of participant plan loans made for each plan year, and
the number and amount of plan loans made to HCEs and NHCEs respectively, affected by the failure for each plan
year.
Number of Plan
Number of Plan
Number of Plan
Amount of Plan
Amount of
Plan Year
Loans Made During
Loans Made to
Loans Made to
Loans
Plan Loans
the Plan Year
NHCEs
HCEs
Description of the Proposed Method of Correction
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the plan
loans that were made available. The effective date of the corrective amendment is
.
D. Early Inclusion of Otherwise Eligible Employee Failure
Employees: (check applicable boxes)
Who had not satisfied the plan’s minimum age or service requirements were treated as eligible participants on a
date prior to their being eligible under the plan and were entitled to the same benefits under the plan to which they
would have been entitled had they completed the minimum age or service requirements of the plan.
14568-I
Catalog Number 66156F
Form
(Rev. 9-2017)

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