Form 14568-C - Model Vcp Compliance Statement Schedule 3 Seps And Sarseps Page 7
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Plan name
EIN
Plan number
Section II - Change in Administrative Procedures
Include an explanation of how and why the failures arose and a description of the measures that have been or will be
implemented to ensure that the same failures will not recur.
Section III - Request for Excise Tax Relief (check applicable boxes)
Excise tax pursuant to IRC Section 4979. The Applicant requests that the IRS not pursue the excise tax under
IRC Section 4979. (This applies only to failures to satisfy the nondiscrimination test for elective deferrals. Enclose
a written explanation in support of your request for relief from this excise tax.)
Excise tax pursuant to IRC Section 4972. The Applicant requests that the IRS not pursue the excise tax under
IRC Section 4972. (This applies to situations where corrective contributions made in accordance with this
submission would be nondeductible contributions for the year of correction and thus would be subject to the
excise tax under IRC Section 4972. Please enclose a written explanation in support of your request for relief from
this excise tax.)
Section IV - Enclosures
● A copy of the applicable plan document in effect at the time of the failures. (This could be an IRS form document,
such as a Form 5305-SEP or 5305A-SEP, or a prototype plan document developed by a financial institution. If a
prototype plan document is used, include a copy of the most recent favorable opinion letter issued for the plan
document).
● A written explanation of how and why the failure(s) described in this submission occurred, including a description of
the administrative procedures applicable to the failure(s) in effect at the time the failure(s) occurred.
● For failures that involve corrective contributions or corrective distributions, a description of assumptions and
supporting calculations used to determine the amounts needed for correction:
1) For failures to satisfy the nondiscrimination test for elective deferrals, computations in support of the proposed
correction, including:
a) The determination of HCEs and NHCEs,
b) The deferral percentages of individual employees and the applicable ADP calculations,
c) The determination of corrective contributions on behalf of NHCEs to correct the ADP test, and
d) Calculations showing how the earnings adjustment and the ultimate corrective contribution on behalf of
affected employees will be determined. (Please use estimates, including an estimated correction date, if
corrective distributions have not been made yet.)
14568-C
Catalog Number 66147U
Form
(Rev. 9-2017)
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