Form 14568-I - Model Vcp Compliance Statement Schedule 9 Limited Safe Harbor Correction By Plan Amendment Page 5

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Page 5
Plan name
EIN
Plan number
Section III - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor
encloses the following with this submission:
● Copies of all amendments used to correct the failure(s), either as adopted or in proposed form. (required)
● A copy of the plan document in effect prior to any of the amendments used to correct the failure(s). (required)
● For an IRC Section 401(a)(17) failure in a defined contribution plan, specific calculations for each affected
employee or a representative sample of affected employees. (The sample calculations must be sufficient to
demonstrate each aspect of the correction method proposed. For example, the determination of the fraction used to
determine the additional amount to be allocated to each employee (other than those for whom there was an IRC
Section 401(a)(17) failure) must be demonstrated.
● For Early Inclusion of Otherwise Eligible Employee Failure, submit a demonstration or analysis that
o Establishes that the corrective amendment is non-discriminatory under IRC Section 401(a)(4). Only include this
item if HCEs benefited from the corrective plan amendment.
o Proves the early inclusion of otherwise eligible employees did not result in an IRC Section 411(d)(6) cutback for
the plan’s other participants.
14568-I
Catalog Number 66156F
Form
(Rev. 9-2017)

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