Form 13069 Draft - Employee Benefit Plan printable pdf download

Form 13069 Draft - Employee Benefit Plan

CYCLE A Submission Period – 02/01/2016 – 01/31/2017

Employee

Explanation No.

Benefit

Section 401(h) and

Section 420

Plans

Determination Of

Qualification

Note:

The purpose of Worksheet Number 13 (Form 13069) and this

explanation is to identify major problems with respect to the re-

Plans submitted during the Cycle A submission period

quirements of Internal Revenue Code section 401(h) in plans

must satisfy the applicable changes in plan qualification

with retiree medical benefit features and on plan provisions

requirements listed in Section IV of Notice 2015-84,

enabling the transfer of assets in a defined benefit plan to a

2015-52 I.R.B. 1 (the 2015 Cumulative List).

health benefit account described in section 401(h), pursuant

to section 420. However, there may be issues not mentioned

in the worksheet that could affect the plan’s qualification.

This publication contains copies of:

Form 13069, Worksheet 13

This worksheet is to be completed if the applicant has spe-

Form 13070, Deficiency Checksheet 13

cifically requested consideration of either section 401(h) or

section 420, relating to transfers of assets in a defined benefit

These forms are included as examples only

plan to a section 401(h) medical benefits account or to an ap-

and should not be completed and returned

plicable life insurance account under section 420(e)(4).

to the Internal Revenue Service.

Generally, a “Yes” answer to a question on the worksheet in-

dicates a favorable conclusion while a “No” answer signals a

problem concerning the plan qualification. This rule may be

altered by specific instructions for a given question. Please

explain any “No” answer in the space provided on the work-

sheet.

The sections cited at the end of each paragraph of explana-

tion are to the Internal Revenue Code and the Income Tax

Regulations.

The technical principles in this publication may be changed

by future regulations or guidelines.

Publication 11433 (Rev. 4-2016) Catalog Number 48816E Department of the Treasury Internal Revenue Service

Form 13069 Draft - Employee Benefit Plan

Related Articles

Related forms

Related Categories