Form 14568-I - Appendix C Part Ii Schedule 9 Correction By Plan Amendment (In Accordance With Appendix B) Page 4

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Page 4
Plan name
EIN
Plan number
Section II - Change in Administrative Procedures
Please include an explanation of how and why the failures arose and a description of the measures that will be implemented to ensure
that the same failures will not recur.
Section III - 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:
● Copies of all amendments used to correct the failure(s), either as adopted or in proposed form. (required)
● A copy of the plan document in effect prior to any of the amendments used to correct the failure(s). (required)
● For a § 401(a)(17) failure in a defined contribution plan, 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 correction method
proposed. For example, the determination of the fraction used to determine the additional amount to be allocated to each
employee (other than those for whom there was a § 401(a)(17) failure) must be demonstrated.
14568-I
Catalog Number 66156F
Form
(1-2014)

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