Form 14568-D - Appendix C Part Ii Schedule 4 Simple Iras Page 6
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Plan name
EIN
Plan number
1) 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 were determined.
b) 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 contributions have not been
made yet.)
2) For failures involving the contribution of Excess Amounts:
a) Computations in support of the excess contribution amounts attributable to each participant.
b) Calculations showing how the Earnings adjustment and the ultimate corrective distribution amounts are determined. (Please
use estimates, including an estimated correction date, if corrective distributions have not been made yet.)
● Explanations in support of requests for excise tax relief.
● Any other information that would be useful for the purpose of understanding the proposals made under the submission.
14568-D
Catalog Number 66148F
Form
(1-2014)
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