Form 14568-C - Appendix C Part Ii Schedule 3 Seps And Sarseps Page 2

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Page 2
Plan name
EIN
Plan number
The interest rate incorporated in the Department of Labor’s Voluntary Fiduciary Correction Program Online Calculator (“VFCP
Online Calculator”) ( ), since the actual Earnings of the affected NHCE’s SARSEP
IRA account cannot be ascertained.
Actual investment results for years in which data is available, or the rate incorporated in the VFCP Online Calculator for years
in which the actual Earnings of the affected NHCE’s SARSEP IRA account cannot be ascertained. The VFCP Online
Calculator was or will be used for the following year(s):
The total corrective contribution (before adjusting for Earnings) on behalf of the affected NHCEs for each plan year is as follows:
Year
Corrective Contribution
Former employees affected by the failure (check one):
There are no former employees affected by the failure.
Affected former employees (or if deceased, their estate or known beneficiary) will be contacted, and corrective contributions
will be made to their SARSEP IRA accounts. To the extent that an affected former employee or beneficiary cannot be located
following a mailing to the last known address, the Plan Sponsor will take the actions specified below to locate that employee or
beneficiary:
After such actions are taken, if an affected employee or beneficiary is not found but is subsequently located on a later date, the
Plan Sponsor will make corrective contributions to the affected SARSEP IRA account at that time.
C. Failure to Make Required Employer Contributions (SEPs or SARSEPs)
The Plan Sponsor failed to make employer contributions on behalf of eligible employees as required under the terms of the plan.
The failure occurred on account of the erroneous exclusion of eligible employees.
Other (describe):
The failure occurred for the following plan year(s):
Description of the Proposed Method of Correction:
The Plan Sponsor has contributed (or will contribute) additional amounts to the plan on behalf of each affected employee. For each
affected employee, the corrective contribution will be determined by calculating the contribution the employee would have been
entitled to under the terms of the plan and subtracting any contributions already made on behalf of the participant for the plan year.
The required contribution made on behalf of an affected participant will be adjusted for Earnings. Earnings will be calculated from
the last day of the plan year for which the failure occurred through the date of the corrective contribution. The corrective
contribution (adjusted for Earnings) will be made to each affected employee’s SEP (or SARSEP, if applicable) IRA account. If an
affected employee does not have a SEP (or SARSEP, if applicable) IRA account, a SEP (or SARSEP, if applicable) account will be
established for that employee.
14568-C
Catalog Number 66147U
Form
(1-2014)

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