Form 14568 - Model Vcp Compliance Statement Page 3

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Page 3
Applicant's EIN (do not use SSN)
Plan number
Plan name
With regard to failure number
(provided that no modification has been made to either the plan document or
adoption agreement of the plan that would otherwise cause the employer to lose reliance on the plan’s opinion or
advisory letter), the corrective amendment will not cause the plan to lose its status as a master or prototype plan or
volume submitter plan and (provided that no modification has been made that would otherwise affect the employer’s
eligibility for the six-year remedial amendment cycle) the employer will be allowed to remain within the six-year
remedial amendment cycle described in Revenue Procedure 2007-44 on a continuing basis until the expiration of the
next six-year remedial amendment cycle as provided in section 18.01 of Rev. Proc. 2007-44, or, if different, the
deadline announced by the IRS, as provided in section 18.03 of that revenue procedure. In addition, the issuance of
this compliance statement constitutes a determination of the effect of the corrective plan amendment on the
qualification of the plan, and a subsequent filing of a determination letter request on such amendment will not be
required until the expiration of the next six-year remedial amendment cycle.
The IRS will not pursue the following on account of the qualification failures described in this submission:
Excise tax under IRC Section 4972
Excise tax under IRC Section 4973
Excise tax under IRC Section 4974
Excise tax under IRC Section 4979
With respect to the overpayment failures described in this compliance statement that were corrected by
removing improper distributions from the IRAs of the affected participants and returning those distributions to the
plan, the IRS will not pursue
% of the 10% additional income tax under IRC Section 72(t).
(For certain VCP submissions made prior to January 1, 2017 only) A determination letter application, required by
section 6.05 of Rev. Proc. 2013-12 (as modified by Rev. Proc. 2015-27) was included with this submission. This
compliance statement is conditioned upon the issuance of a favorable determination letter for the plan as a result of
determination letter application control number
. If one or more of the failures described in this compliance
statement are being corrected by proposed plan amendments the plan sponsor may adopt such amendments by the
later of: (a) one hundred fifty (150) days following the date of the compliance statement or (b) ninety-one (91) days
after the issuance of a favorable determination letter for the application. For governmental plans within the meaning
of IRC Section 414(d), the deadline to adopt these amendments is further extended to the 91st day after the close of
the first legislative session that begins more than one hundred twenty (120) days after a favorable determination
letter is issued for the application.
With respect to the loan failures described in this compliance statement:
For all loans that are corrected by a corrective repayment to the plan or reamortization as described in this
compliance statement: The IRS will not require deemed distributions under IRC Section 72(p) to be reported on
Form 1099-R with respect to the participants affected by the failures, and repayments made pursuant to the
correction of such loans will not result in an affected participant having additional basis in the plan for the
purpose of determining the tax treatment of subsequent distributions from the plan to such participants.
For all loans that will be reported as deemed distributions. The IRS will require deemed distributions under IRC
Section 72(p) to be reported on Form 1099-R with respect to the participants affected by the failures. However,
the plan will be permitted to report deemed distributions on Form 1099-R in the year of correction, instead of the
year of the failure.
14568
Catalog Number 66138J
Form
(Rev. 9-2017)

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