Form 14568-C - Appendix C Part Ii Schedule 3 Seps And Sarseps Page 6
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Plan name
EIN
Plan number
The Earnings adjustment will be based on the actual rates of return of the SEP or SARSEP from the date(s) that the excess
employer contributions were made through the date of correction.
Excess Amounts of $100 or less (See section 6.02(5)(e) of Rev. Proc. 2013-12.)
For one or more participants, the total Excess Amount (employer contributions and/or elective deferrals before adjusting for
Earnings) is $100 or less. The Excess Amount will not be distributed.
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 - Request(s) For Excise Tax Relief (check applicable boxes)
Excise tax pursuant to § 4979. The Applicant requests that the Service not pursue the excise tax under § 4979. (This applies
only to failures to satisfy the nondiscrimination test for elective deferrals. See section 6.09(4) of Rev. Proc. 2013-12 for an
example of a situation where a request for relief under § 4979 would be considered. Please enclose a written explanation in
support of your request for relief from this excise tax.)
Excise tax pursuant to § 4972. The Applicant requests that the Service not pursue the excise tax under § 4972. (This applies
to situations where corrective contributions made in accordance with this submission would be nondeductible contributions for
the year of correction and thus would be subject to the excise tax under § 4972. See section 6.09(3) of Rev. Proc. 2013-12.
Please enclose a written explanation in support of your request for relief from this excise tax.)
Section IV - 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:
● The applicable plan document. (This could be an IRS form document, such as a Form 5305-SEP or 5305A-SEP, or a prototype
plan document developed by a financial institution. If a prototype plan document is used, include a copy of the most recent
favorable opinion letter issued for such plan document).
● A written explanation of how and why the failure(s) described in this submission occurred, including a description of the
administrative procedures applicable to the failure(s) in effect at the time the failure(s) occurred.
● For failures that involve corrective contributions or corrective distributions, a description of assumptions and supporting
calculations used to determine the amounts needed for correction:
1) For failures to satisfy the nondiscrimination test for elective deferrals, computations in support of the proposed correction,
including:
a) The determination of HCEs and NHCEs,
b) The deferral percentages of individual employees and the applicable ADP calculations,
c) The determination of corrective contributions on behalf of NHCEs to correct the ADP test, and
d) Calculations showing how the Earnings adjustment and the ultimate corrective contribution on behalf of affected employees
will be determined. (Please use estimates, including an estimated correction date, if corrective distributions have not been
made yet.)
2) For failures to make required employer contributions and for failures to provide eligible employees with the opportunity to make
elective deferrals:
a) Computations in support of the corrective contribution amounts attributable to each participant. In the case of a failure to
provide eligible employees with the opportunity to make elective deferrals, please include computations showing how the
average deferral percentage, missed deferral, and corrective contribution amount was determined, and
14568-C
Catalog Number 66147U
Form
(1-2014)
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