Department of the Treasury - Internal Revenue Service
Model VCP Compliance Statement - Schedule 4
Include the plan name, Applicant’s EIN and plan number on each page of the compliance statement, including attachments
Section I - Identification of Failure(s) and Proposed Method(s) of Correction
The following failure(s) occurred with respect to the SIMPLE IRA plan identified above (Check failure(s) that apply. Within
each failure, check applicable boxes, and provide the information requested.)
A. Employer Eligibility Failure
The plan was adopted by a plan sponsor who was (or subsequently became) ineligible to sponsor a SIMPLE IRA
plan under the requirements of Section 408(p) of the Internal Revenue Code (IRC) because the plan sponsor
(and, if applicable, its related controlled group or affiliated service group employers) had more than 100
employees (including leased employees, if applicable) who earned $5,000 or more in compensation during the
following plan year(s)
The plan was adopted by a plan sponsor who was not eligible to sponsor a SIMPLE IRA plan under the
requirements of IRC Section 408(p) because the plan sponsor established or maintained a another tax favored
retirement plan under IRC Sections 401(a), 403(b) and 408(k)with respect to which contributions were made (or
under which benefits were accrued) during any plan year of the SIMPLE IRA plan. The failure occurred during the
following plan year(s)
Description of the Proposed Method of Correction
All contributions to the plan ceased as of
(insert a date no later than the date this
VCP submission is filed with the IRS). The plan sponsor will not permit any new employer or salary reduction
contributions to be made to the plan.
B. Failure to Make Required Employer Contributions
The plan sponsor failed to make employer contributions on behalf of eligible employees as required under the terms
of the plan.
The failure occurred on account of the erroneous exclusion of eligible employees
The failure occurred due to errors in the determination of compensation for eligible employees
The failure occurred for the following plan year(s)
For the applicable plan years, the provisions of the plan document required the plan sponsor to make employer
contributions based on the following formula:
2% nonelective contribution on behalf of each eligible employee who earned at least $5,000 in compensation for
Matching contribution on behalf of each eligible employee equal to deferrals up to 3% of compensation.
Grace period applied. The plan provided for a matching contribution on behalf of each eligible employee equal to
deferrals up to
% of compensation.
(Note: If the failure occurred for multiple plan years and different employer contribution criteria applied during those
years, check the applicable box, and indicate the plan years for which the formula applied.)
Catalog Number 66148F
For Paperwork Reduction Act information see current EPCRS Revenue Procedure.