Form 14568-E - Model Vcp Compliance Statement Schedule 5 Plan Loan Failures (Qualified Plans And 403(B) Plans) Page 5
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Plan name
EIN
Plan number
D. Correction for Deemed Distributions (check if applicable)
The plan sponsor is not eligible to or will not correct in accordance with Parts IV A through IV C of this compliance
statement. The plan sponsor proposes that the loans be reported as deemed distributions (using Form 1099-R)
for the year of correction instead of the year of the failure. The plan sponsor shall pay any applicable income tax
withholding amount that was required to be paid in connection with the failure. (See Income Tax Regulations
Section 1.72(p)-1, Q&A-15.)
Section V - Change in Administrative Procedures
Include a description of the measures that have been (or will be) implemented to ensure that the same failures will not
recur.
Section VI - Request for Relief
Yes No
The plan sponsor requests relief from reporting all participant loans as deemed distributions.
Yes No
The plan sponsor requests that the plan be permitted to report all participant loans as deemed distributions
in the year of correction instead of the year of the failure.
Yes No
The plan sponsor requests that for one or more of the participant loans described in this compliance
statement that it be permitted to report the participant loans(s) as deemed distributions in the year of
correction instead of the year of the failure. For other affected participant loan(s), the plan sponsor requests
relief from reporting them as deemed distributions. Details relating to this request are as follows
Section VII - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor
encloses the following with this submission:
• A copy of the original loan agreement for each affected participant (a sample representation may be provided if there
are multiple participants affected).
• Loan amortization schedules for affected participants. Include a copy of the original loan amortization schedule and if
applicable, a copy of the modified loan amortization schedule (a sample representation may be provided if there are
multiple participants affected).
• A detailed explanation as to how you determined the user fee for this submission. If you qualify for a reduced fee, be
sure to include the number of participants with plan loans that do not comply with IRC Section 72(p) and a calculation
that shows no more than 25% of plan participants were affected in any plan year
• Specific calculations for each affected employee or a representative sample of affected employees. (The sample
calculations must be sufficient to demonstrate each aspect of the correction method proposed (for example, a failure
with respect to a loan that exceeds the maximum amount permitted by IRC Section 72(p)(2)(A), the calculations must
include the amounts of the excess loan amounts that will be repaid to the plan, determination of the outstanding loan
balance, and the proposed method of repayment of the outstanding loan balance; for the correction of a defaulted
loan, the enclosure should set forth the periods of such loan defaults.)
14568-E
Catalog Number 66149Q
Form
(Rev. 9-2017)
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