Form 14568-D - Appendix C Part Ii Schedule 4 Simple Iras Page 4
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Plan name
EIN
Plan number
Description of the Proposed Method of Correction (check all correction methods that apply):
Distribution of Excess Elective Deferrals
The Plan Sponsor has effected (or will effect) a distribution of the Excess Amounts, adjusted for Earnings through the date of
correction, to the affected participant(s). The Earnings adjustment will be based on the actual rates of return of the participant’s
SIMPLE IRA account from the date(s) that the excess deferrals were made through the date of correction.
Affected participants were (or will be) informed that the distribution of an Excess Amount is not eligible for favorable tax
treatment accorded to distributions from a SIMPLE IRA and, specifically, is not eligible for tax-free rollover.
The total corrective distribution (before adjusting for Earnings) for each affected plan year is as follows:
Year
Corrective Distribution
Number of Participants Affected
Distribution of Excess Employer Contributions
The Plan Sponsor has effected (or will effect) the return of excess employer contributions, adjusted for Earnings through the
date of correction, to the Plan Sponsor. The Earnings adjustment will be based on the actual rates of return on the affected
participants’ SIMPLE IRA accounts from the date(s) that the excess employer contributions were made through the date of
correction. The amount returned to the Plan Sponsor is not includible in the gross income of the affected participant(s). The
Plan Sponsor is not entitled to a deduction for such excess employer contributions. The amount returned is reported on Form
1099-R as a distribution issued to the affected participant(s), indicating the taxable amount as zero.
The return of the excess employer contributions (before adjusting for Earnings) for each affected plan year is as follows:
Year
Return of Excess Employer Contributions
Number of Participants Affected
Retention of Excess Amounts
Note: If this correction method is selected, an additional VCP fee is required. (See section 12.06(2) of Rev. Proc. 2013-12.)
The Excess Amounts (including Earnings) were retained in the SIMPLE IRA accounts of the affected participants as follows:
Year
Excess Amounts Retained
Number of Participants Affected
14568-D
Catalog Number 66148F
Form
(1-2014)
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