Form 13069 Draft - Employee Benefit Plan Page 5

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CYCLE A Submission Period – 02/01/20165 – 01/31/2017
Employee Benefit Plan
Sections 401(h) and 420
(Worksheet Number 13 – Determination of Qualification)
Instructions – All items must be completed. A “Yes” answer generally indicates a favorable conclusion is warranted, while a “No”
answer indicates a problem exists. Please use the space on the worksheet to explain any “No” answer. Numbers in brackets refer to
EDS paragraph numbers. See Publication 11433, Explanation Number 13, for guidance in completing this form.
The technical principles in this worksheet may be changed by future regulations or guidelines.
Name of plan
I. Retiree Medical Benefits
Plan Reference
Yes
No
N/A
a. Has the applicant requested consideration under section 401(h) or 420 relative to
retiree medical benefits? (If “Yes,” see section 16 and appendix of Rev. Proc.
2015-6, 2015-1 I.R.B. 194, and complete the remainder of this worksheet. If “No,”
go to section VI of this worksheet.) [1375]
b. Does the plan contain a medical benefits account within the meaning of section 401
(h)? (If “Yes,” complete the remainder of this worksheet. If “No,” secure
amendments to include the section 401(h) account provisions or request an
explanation from the applicant and go to Section VI of this worksheet.) [1375]
c. Is the section 401(h) medical benefits account part of a pension or annuity plan
(including a money purchase pension plan)? [1376]
d. Does the plan specify the medical benefits that will be available and contain
provisions for determining the amount that will be paid? [1376]
e. Does the medical benefits account specify who will benefit and limit eligible persons
to retired employees, their spouses and their dependents? [1377]
f. Does the plan specify either that contributions to the medical benefits account are
provided entirely from employer contributions or that they will be paid from employer
and employee contributions? [1378]
II. Subordination – Retiree Medical Benefits
Plan Reference
Yes
No
N/A
a. Does the plan provide that retiree medical benefits are subordinate to the retirement
benefits such that the aggregate actual contributions for medical benefits, when
added to actual contributions for life insurance protection under the plan (excluding
any amounts transferred to or paid from an applicable life insurance account, if
applicable), do not exceed 25 percent of the total actual contributions to the plan
(other than contributions to fund past service credits) after the later of the adoption
or effective date of the plan amendment establishing the section 401(h) account?
[1379]
III. Separate Accounts – Retiree Medical Benefits
Plan Reference
Yes
No
N/A
a. Does the plan provide that the section 401(h) arrangement for retiree medical
benefits is a separate account established and maintained for such benefits? [1380]
b. Does the plan provide that in the case of an employee who is a key employee, a
separate account is established and maintained for retiree medical benefits payable
to such employee (and his spouse and dependents) and such benefits (to the extent
attributable to plan years beginning after March 31, 1984, for which the employee is
a key employee) are only payable to such employee (and his spouse and
dependents) from such separate account? [1381]
c. Does the plan provide that the term “key employee” means any employee, who at
any time during the plan year or any preceding plan year during which contributions
were made on behalf of such employee, is or was a key employee as defined in
section 416(i)? [1381]
IV. Reasonable and Ascertainable Provisions – Retiree Medical Benefits
Plan Reference
Yes
No
N/A
a. Does the plan provide for employer contributions to the medical benefits account
that are reasonable and ascertainable? [1382]
13069
Catalog Number 31858W
publish.no.irs.gov
Department of the Treasury - Internal Revenue Service
Form
(Rev. 4-2016)

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