Form 14568-D - Model Vcp Compliance Statement Schedule 4 Simple Iras Page 4
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Plan name
EIN
Plan number
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 IRA. 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.
D. Excess Amounts Contributed
The plan sponsor contributed excess amounts to the plan on behalf of participants as follows (check boxes that apply)
Amounts were contributed in excess of the benefit the participants were entitled to under the plan.
Elective deferrals were made to the SIMPLE IRA in excess of the limitation under the terms of the SIMPLE IRA
(the applicable limit under IRC Section 408(p)(2)(E)).
The total of the excess amounts for each affected plan year was as follows
Year
Excess Amounts
Number of Participants Affected
Description of the Proposed Method of Correction (check all correction methods that apply)
Distribution of excess elective deferrals
The plan sponsor has effected (or will effect) a distribution of the excess amounts, adjusted for earnings through
the date of correction, to the affected participant(s). The earnings adjustment will be based on the actual rates of
return of the participant’s SIMPLE IRA from the date(s) that the excess deferrals were made through the date of
correction.
Affected participants were (or will be) informed that the distribution of an excess amount is not eligible for
favorable tax treatment accorded to distributions from a SIMPLE IRA and, specifically, is not eligible for tax-free
rollover.
The total corrective distribution (before adjusting for earnings) for each affected plan year is
Year
Corrective Distribution
Number of Participants Affected
14568-D
Catalog Number 66148F
Form
(Rev. 9-2017)
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