Department of the Treasury - Internal Revenue Service
14568
OMB Number
Form
Model VCP Compliance Statement
1545-1673
(September 2017)
Include the plan name, Applicant’s EIN and plan number on each page of the compliance statement, including attachments
Section I - Identifying Information
1. Applicant's name
2. Applicant's EIN (do not use SSN)
3. Plan number
4. Plan name
Section II - Applicant's Description of Failures
Attach additional pages, as needed. Label the attachment “Section II. Applicant’s Description of Failures.” List and
number each failure separately. If using the Form 14568 Schedules, specify the Schedules that are included and attach
them to this compliance statement.
Section III - Applicant’s Description of the Proposed Method of Correction
Attach additional pages, as needed. Label the attachment “Section III. Applicant’s Description of the Proposed
Method of Correction.” Describe the correction method for each failure listed in Section II. If using the Form 14568
Schedules, specify the Schedules that are included and attach them to this compliance statement.
Section IV - Applicant’s Proposed Procedures to Locate and Notify Former Employees or Beneficiaries
Attach additional pages, as needed. Label the attachment “Section IV. Applicant’s Proposed Procedures to Locate
and Notify Former Employees or Beneficiaries.” Describe the methods that will be used to locate and notify former
employees and beneficiaries, or provide an affirmative statement that no former employees or beneficiaries were affected
by each failure listed in Section II or will be affected by the correction methods described in Section III.
Section V - Applicant’s Proposed Revision to Administrative Procedures
Attach additional pages, as needed. Label the attachment “Section V. Applicant’s Proposed Revision to
Administrative Procedures.” Include an explanation of how and why the failures arose and a description of the
measures implemented (or will be implemented) to ensure that the same failures do not occur in the future. If using the
Form 14568 Schedules, specify the Schedules that are included and attach them to this compliance statement.
Section VI - Requests Related to Excise Taxes, Additional Tax and Tax Reporting
The Applicant requests that the Internal Revenue Service (IRS) not pursue the following taxes under the Internal
Revenue Code (IRC) (attach supporting rationale)
Excise tax under IRC Section 4972 with respect to failures number
Excise tax under IRC Section 4973 with respect to failures number
Excise tax under IRC Section 4974 with respect to failures number
Excise tax under IRC Section 4979 with respect to failures number
Imposition of additional tax under IRC Section 72(t) with respect to failures number
14568
Catalog Number 66138J
Form
(Rev. 9-2017)
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.