Form 14568-D - Model Vcp Compliance Statement Schedule 4 Simple Iras Page 2

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Plan name
EIN
Plan number
Description of the Proposed Method of Correction
The plan sponsor has contributed (or will contribute) additional amounts to the plan on behalf of each affected
employee. For each affected employee, the corrective contribution will be determined by calculating the contribution
the employee would have been entitled to receive under the terms of the plan and subtracting any contributions
already made on behalf of the employee for the plan year. The corrective contribution made on behalf of an affected
employee will be adjusted for earnings. Earnings will be calculated from the last day of the plan year for which the
failure occurred through the date of the corrective contribution. The corrective contribution (adjusted for earnings) will
be made to each affected employee’s SIMPLE IRA. If an affected employee does not have a SIMPLE IRA, an account
will be established for that employee.
If the plan did not provide eligible employees with the opportunity to make elective deferrals and the plan provides for
matching contributions, the corrective matching contribution will be based on the assumption that the eligible
employee would have made an elective deferral equal to 3% of compensation.
The total corrective contribution (before adjusting for earnings) for each plan year is
Year
Corrective Contribution
The earnings calculation for an affected employee will be based on one of the following methods (check one)
Actual investment results of the affected employee’s SIMPLE IRA.
The interest rate incorporated in the Department of Labor’s Voluntary Fiduciary Correction Program Online
Calculator (VFCP Online Calculator) ( ), since the actual earnings of
the affected employee’s IRA cannot be ascertained.
Actual investment results for years in which data for the affected employee is available, and the rate incorporated
in the VFCP Online Calculator for years in which the actual investment results of the affected employee’s IRA
cannot be ascertained. The VFCP Online Calculator was or will be used for the following year(s)
Former employees affected by the failure (check one)
There are no former employees affected by the failure.
Affected former employees (or if deceased, their estate or known beneficiary) will be contacted, and corrective
contributions will be made to their SIMPLE IRAs. To the extent that an affected former employee or beneficiary
cannot be located following a mailing to the last known address, the plan sponsor will take the actions specified
below to locate that employee or beneficiary
After such actions are taken, if an affected employee or beneficiary is not found but is located at a later date, the
plan sponsor will make corrective contributions to the affected SIMPLE IRA at that time.
14568-D
Catalog Number 66148F
Form
(Rev. 9-2017)

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