Form 14568-E - Model Vcp Compliance Statement Schedule 5 Plan Loan Failures (Qualified Plans And 403(B) Plans) Page 2

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Page 2
Plan name
EIN
Plan number
D. Defaulted loan(s) (where the loan terms satisfied the requirements of IRC Section 72(p)(2), but default(s)
occurred because loan payments were not made in accordance with the terms of the loan)
Plan Year
Number of Participants Affected
Total Number of Loans in Default
Section II - Eligibility for Use of Form 14568-E
Yes No
A.
Is any affected participant either a key employee (as defined in IRC Section 416(i)(1)) or an owner-
employee (as defined in IRC Section 401(c)(3))?
If “Yes,” proceed to Section II B.
If “No,” skip Section II B and proceed to Section II C.
Yes No
B.
Is the purpose of this request limited to permitting the plan sponsor to report the loan as a deemed
distribution in the year of correction instead of the year of the failure?
If “Yes,” complete Section III and then proceed directly to Section IV D. (Sections IV A, B and C do
not apply.)
If “No,” STOP-do NOT use this Form 14568-E. Any request for relief should be made by filing a
detailed written attachment to Form 14568, Model VCP Compliance Statement, describing the relief
requested and the reasons why such relief should be granted.
Yes No
C.
Will correction be completed before the maximum period for repayment of the loan (pursuant to IRC
Section 72(p)(2)(B)) has expired? (Note: The maximum period is determined from the original date of
the loan. Generally, this period is five years from the original date of the loan, except for home loans as
described in IRC Section 72(p)(2)(B)(ii).) The original date of the loan is considered to be the date the
participant received the proceeds from the loan.
If ”Yes,” and the plan sponsor wants relief from reporting the loan as a deemed distribution, complete
Section III and then answer applicable questions in Sections IV A through IV C.
If “No,” complete Section III and then proceed to Section IV D.
Section III - Explanation of How and Why the Plan Loan Failures Occurred
14568-E
Catalog Number 66149Q
Form
(Rev. 9-2017)

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