Form 14568-H - Model Vcp Compliance Statement Schedule 8 Failure To Pay Required Minimum Distributions Timely Page 2
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Plan name
EIN
Plan number
Defined benefit plan only – At the time of the proposed correction is the plan subject to any restriction on lump
sum payments under IRC Section 436(d)? Include a copy of the plan’s most current actuarial certification of the
plan’s Adjusted Funded Target Attainment Percentage (AFTAP) if “No” is checked.
Yes No
If "Yes", the plan sponsor will contribute to the plan, at the time of correction, an amount equal to the corrective
distribution mentioned in this compliance statement as discussed in the current EPCRS revenue procedure.
Section III - Request for Relief
A. The Applicant requests relief with regard to excise taxes under IRC Section 4974
Yes No
At least one affected participant is either an owner-employee (see IRC Section 401(c)(3)) or, if the plan
sponsor is a corporation, a 10 percent owner of such corporation.
If “Yes,” the Applicant submits the following explanation for its request for relief from the Section 4974 excise tax
Section IV - 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 V - 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 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 total number of plan participants with RMD failures. The reduced user fee does not apply if plan
benefits did not commence in a timely manner at the plan’s normal retirement age or upon the participant’s death.
• 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 proposed correction method.
• For defined benefit plans, the calculations must illustrate the interest rate used to represent the loss of the use of the
missed required minimum distributions.
• For defined contribution plans, the calculations must show how earnings were determined and their impact on the
calculation of the corrective distributions.
• For defined benefit plans, a copy of the plan’s most current AFTAP certification if the Applicant has indicated that the
plan is not under IRC 436(d) restrictions.
14568-H
Catalog Number 66153Y
Form
(Rev. 9-2017)
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