Form 14568-E - Appendix C Part Ii Schedule 5 - Plan Loan Failures (Qualified Plans And 403(B) Plans) Page 4

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Plan name
EIN
Plan number
The interest rate for missed payments was determined as follows:
The additional unpaid interest (
will be /
has been
(check one)) paid by the: (check the box that applies)
Plan Sponsor
Affected participants
(Note: Irrespective of the Plan Sponsor’s election to have the affected participants pay the unpaid interest, in accordance with
section 6.02(6) of Rev. Proc. 2013-12, the Service may, based on the facts and circumstances, determine that the Plan Sponsor
should pay all or a portion of the additional unpaid interest. If the Service makes this determination, the Plan Sponsor will be
requested to revise this submission.)
D. Correction for Deemed Distributions (check if applicable)
The Plan Sponsor is not eligible to or will not correct in accordance with Parts IV A through IV C of this Appendix C, Part II
Schedule 5. The Plan Sponsor proposes that the loans be reported as deemed distributions (using Form 1099 R) for the year
of correction instead of the year of the failure. The Plan Sponsor shall pay any applicable income tax withholding amount that
was required to be paid in connection with the failure. (See Income Tax Regulations § 1.72(p)-1, Q&A-15.)
Section V - Description of Steps Taken to Ensure That the Failure Does Not Recur
Section VI - Request for Relief
Yes
No
The Plan Sponsor requests relief from reporting participant loans as deemed distributions.
Yes
No
The Plan Sponsor requests that the plan be permitted to report the participant loans as deemed distributions in the year
of correction instead of the year of the failure.
Section VII - 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:
● Loan amortization schedules for affected participants. (A sample representation may be provided if there are multiple
participants affected.)
● 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 (e.g., for a failure with respect to a loan that
exceeds the maximum amount permitted by § 72(p)(2)(A), the calculations must include the amounts of the excess loan
amounts that will be repaid to the plan, determination of the outstanding loan balance, and the proposed method of repayment of
the outstanding loan balance; for the correction of a defaulted loan, the enclosure should set forth the periods of such loan
defaults.)
14568-E
Catalog Number 66149Q
Form
(1-2014)

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