Form 14568-D - Appendix C Part Ii Schedule 4 Simple Iras
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6Department of the Treasury - Internal Revenue Service
14568-D
Form
OMB Number
Appendix C Part II Schedule 4
1545-1673
(January 2014)
Simple IRAs
Please include the plan name, Applicant’s EIN, and plan number information on each page of the submission, including attachments
Plan name
EIN
Plan number
Section I - Identification of Failure(s) and Proposed Method(s) of Correction
The following failure(s) occurred with respect to the SIMPLE IRA Plan identified above: (Check failure(s) that apply. Within each failure,
check applicable boxes, and provide the information requested.)
A. Employer Eligibility Failure
The plan was adopted by a Plan Sponsor who was (or subsequently became) ineligible to sponsor a SIMPLE IRA Plan under
the requirements of § 408(p) because the Plan Sponsor (and, if applicable, its related controlled group or affiliated service
group employers) had more than 100 employees (including leased employees, if applicable) who earned $5,000 or more in
compensation during the following plan year(s):
The plan was adopted by a Plan Sponsor who was not eligible to sponsor a SIMPLE IRA Plan under the requirements of
§ 408(p) because the Plan Sponsor established or maintained a Qualified Plan with respect to which contributions were made
(or under which benefits were accrued) during any plan year of the SIMPLE IRA Plan. The failure occurred during the following
plan year(s):
Description of the Proposed Method of Correction:
All contributions to the plan ceased as of
(insert a date no later than the date this VCP
submission is filed with the Service). The Plan Sponsor will not permit any new employer or salary reduction contributions to
be made to the plan.
B. Failure to Make Required Employer Contributions
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 years:
For the applicable plan years, the provisions of the plan document required the Plan Sponsor to make employer contributions
based on the following formula:
2% nonelective contribution on behalf of each eligible employee who earned at least $5,000 in compensation for the year.
Matching contribution on behalf of each eligible employee equal to deferrals up to 3% of compensation.
Grace period applied. The plan provided for a matching contribution on behalf of each eligible employee equal to deferrals up
to
% of compensation.
(Note: If the failure occurred for multiple plan years and different employer contribution criteria applied during those years, check
the applicable box, and indicate the plan years for which the formula applied.)
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 receive under the terms of the plan and subtracting any contributions already made on behalf of the employee for the
plan year. The corrective contribution made on behalf of an affected employee 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 SIMPLE IRA account. If an affected
employee does not have a SIMPLE IRA account, an account will be established for that employee.
14568-D
Catalog Number 66148F
Form
(1-2014)
For Paperwork Reduction Act information see Revenue Procedure 2013-12.
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