Form 14568-D - Model Vcp Compliance Statement Schedule 4 Simple Iras Page 6
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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 if applicable)
Excise tax pursuant to IRC Section 4972. The plan sponsor 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 subject to the excise tax under
IRC Section 4972. Enclose a written explanation in support of your request for relief from this excise tax.)
Section IV - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor
encloses with this submission:
● A copy of the applicable plan document in effect at the time of the failure(s). (This could be an IRS form document,
such as a 5305-SIMPLE or 5304-SIMPLE, or a prototype document developed by a financial institution. If a
prototype plan document is used, please send a copy of the most recent opinion letter issued with respect to such
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.
● If the plan was not timely updated for EGTRRA, include a copy of the updated document that was adopted by the
plan sponsor.
● For failures that involve corrective contributions or corrective distributions, a description of assumptions and
supporting calculations used to determine the amount needed for correction:
1) For failures to make required employer contributions and for failures to provide eligible employees with the
opportunity to make elective deferrals:
a) Computations in support of the corrective contribution amounts attributable to each participant. In the case of a
failure to provide eligible employees with the opportunity to make elective deferrals, please include
computations showing how the average deferral percentage, missed deferral and corrective contribution
amount were determined.
b) 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 contributions have not been made yet.)
2) For failures involving the contribution of excess amounts:
a) Computations in support of the excess contribution amounts attributable to each participant.
b) Calculations showing how the earnings adjustment and the ultimate corrective distribution amounts are
determined. (Please use estimates, including an estimated correction date, if corrective distributions have not
been made yet.)
● Explanations in support of requests for excise tax relief.
● Any other information that would be useful for the purpose of understanding the proposals made under the
submission.
14568-D
Catalog Number 66148F
Form
(Rev. 9-2017)
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