Voluntary Fiduciary Correction Program
Application Form
This application form provides a recommended format for your VFC Program application. Please make sure you have attached all documents identified on the VFC Program Checklist (for example, proof of payment). Submit your application to the appropriate EBSA field office. For full application procedures, consult www.dol.gov/ebsa/.
Applicant Name(s) and Address(es)
List separately:
List Transaction(s) Corrected
Check which transaction(s) listed in the VFC Program you have corrected:
___ Delinquent Participant Contributions and Participant Loan Repayments to Pension Plans
___ Delinquent Participant Contributions to Insured Welfare Plans
___ Delinquent Participant Contributions to Welfare Plan Trusts
___ Loan at Fair Market Interest Rate to a Party in Interest
___ Loan at Below-Market Interest Rate to a Party in Interest
___ Loan at Below-Market Interest Rate to a Non-Party in Interest
___ Loan at Below-Market Interest Rate Due to Delay in Perfecting Plan’s Security Interest
___ Loans Failing to Comply with Plan Provisions for Amount, Duration or Level Amortization
___ Default Loans
___ Purchase of an Asset by a Plan from a Party in Interest
___ Sale of an Asset by a Plan to a Party in Interest
___ Sale and Leaseback of Real Property to Employer
___ Purchase of Asset by a Plan from a Non-Party in Interest at More Than Fair Market Value
___ Sale of an Asset by a Plan to a Non-Party in Interest at Less Than Fair Market Value
___ Holding of an Illiquid Asset Previously Purchased by a Plan
___ Payment of Benefits Without Properly Valuing Plan Assets on Which Payment is Based
___ Duplicative, Excessive, or Unnecessary Compensation Paid by a Plan
___ Expenses Improperly Paid by a Plan
___ Payment of Dual Compensation to a Plan Fiduciary
Narrative and Calculations
List:
(1) all persons materially involved in the Breach and its correction (e.g., fiduciaries, service providers):
(2) An explanation of the Breach, including the date(s) it occurred (attach separate sheets if necessary): ______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
(3) An explanation of how the Breach was corrected, by whom, and when (attach separate sheets if necessary): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(4) For correction of Delinquent Remittance of Participant Funds, provide a statement from a Plan Official identifying the earliest date on which participant contributions/loan repayments reasonably could have been segregated from the employer’s general assets (attach supporting documentation on which Plan Official relied):
Number of days used to determine the date on which participant contributions/loan repayments withheld from employees’ pay could reasonably have been segregated from the employer’s general assets: ____
Description of how this was determined: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
(5) For correction of Delinquent Remittance of Participant Funds, provide a narrative describing the applicant's contribution and/or repayment remittance practices before and after the period of unpaid or late contributions and/or repayments: (attach separate sheets if necessary) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(6) Specific calculations demonstrating how Principal Amount and Lost Earnings or Restoration of Profits was calculated (attach separate sheets if necessary): If the Online Calculator was used, you only need to indicate this and attach a copy of the “Printable Results” page.
___ Online Calculator – “Printable Results” page attached
___ Manual calculation – see attached calculations
(1) Plan Sponsor Name: ___________________________________________________________________________
EIN: _____________________________________
Address: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(2) Plan Name: ___________________________________________________________________________
Plan Number: ________________________
(3) Plan Administrator Name: ___________________________________________________________________________
EIN: _____________________________________
Address: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(4) Name of Authorized Representative: (Submit written authorization signed by the Plan Official.)
___________________________________________________________________________
Address: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Telephone: _______________________________
(5) Name of Contact Person: ___________________________________________________________________________
Address:
_____________________________________________________________________________________________________________________________________________________
___________________________________________________________________________Telephone: ______________________________
(6) Date of Most Recent Annual Report Form 5500 Filing: ___ /___ /____ for Plan Year Ending: ___ /___ /___
(7) Is Applicant Seeking Relief Under PTE 2002-51?
___ Yes - Either:
___ Submit a copy of the notice to interested parties within 60 calendar days of this application and indicate date of the notice if not on the notice itself; or
___ If you are relying on the exception to the notice requirement contained in section IV.C. of PTE 2002-51, provide a copy of a completed IRS Form 5330 or other written documentation and proof of payment.
___ No
(8) Proof of Payment
___ Canceled check
___ Executed wire transfer
___ Signed, dated receipt from the recipient of funds transferred to the plan (such as a financial institution)
___ Bank statements for the plan's account
___ Other: _______________________________________________________________
(9) Disclosure of a current investigation or examination of the plan by an agency, to comply with Section 3(b)(3)(v):
___ PBGC
___ Any state attorney general State: ________________
___ Any state insurance commissioner State: ________________
Contact person for the agency identified: ______________________
(10) In order to help us improve our service, please indicate how you learned about the VFC Program: ___________________________________________________________
Attach supporting documentation here.
Name of Plan Official _________________________________________________________________________
Signature of Plan Official _________________________________________________________________________
The following statement must be signed and dated by a plan fiduciary with knowledge of the transaction that is the subject of the application and by the authorized representative, if any. Each Plan Official applying under the VFC Program must also sign and date the statement, which must accompany any subsequent additions to the application.
“Under penalties of perjury I certify that I am not Under Investigation (as defined in VFC Program Section 3(b)(3)) and that I have reviewed this application, including all supporting documentation, and to the best of my knowledge and belief the contents are true, correct, and complete.”
__________________________________________________________________________
Name and Title
Signature __________________________________________________________________________
Date ___________________
__________________________________________________________________________
Name and Title
Signature __________________________________________________________________________
Date ___________________
Paperwork Reduction Act Notice
The information identified on this form is required for a valid application for the Voluntary Fiduciary Correction Program of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). You are not required to use this form; however, you must supply the information identified in order to receive the relief offered under the Program with respect to a breach of fiduciary responsibility under Part 4 of Title I of ERISA. EBSA will use this information to determine whether you have satisfied the requirements of the Program. EBSA estimates that assembling and submitting this information will require an average of 6 to 8 hours. This collection of information is currently approved under OMB Control Number 1210-0118. You are not required to respond to a collection of information unless it displays a currently valid OMB Control Number.
Use this checklist to ensure that you are submitting a complete application. The applicant must sign and date the checklist and include it with the application. Indicate “Yes”, “No” or “N/A” next to each item. A “No” answer or the failure to include a completed checklist will delay review of the application until all required items are received.
______ 1. Have you reviewed the eligibility, definitions, transaction and correction, and documentation sections of the VFC Program?
______ 2. Have you included the name, address and telephone number of a contact person familiar with the contents of the application?
______ 3. Have you provided the EIN, Plan Number, and address of the plan sponsor and plan administrator?
______ 4. Have you provided the date that the most recent Form 5500 was filed by the plan?
______ 5. Have you enclosed a signed and dated certification under penalty of perjury for the plan fiduciary with knowledge of the transactions and for each applicant and the applicant's representative, if any?
______ 6. Have you enclosed relevant portions of the plan document and any other pertinent documents (such as the adoption agreement, trust agreement, or insurance contract) with the relevant sections identified?
______ 7. If applicable, have you provided written notification to EBSA of any current investigation or examination of the plan, or of the applicant or plan sponsor in connection with an act or transaction directly related to the plan by the PBGC, any state attorney general, or any state insurance commissioner?
______ 8. Where applicable, have you enclosed a copy of an appraiser's report?
______ 9. Have you enclosed supporting documentation, including:
______ a. A detailed narrative of the Breach, including the date it occurred;
______ b. Documentation that supports the narrative description of the transaction;
______ c. An explanation of how the Breach was corrected, by whom and when, with supporting documentation;
______ d. A list of all persons materially involved in the Breach and its correction (e.g., fiduciaries, service providers, borrowers, lenders);
______ e. Specific calculations demonstrating how Principal Amount and Lost Earnings or Restoration of Profits were computed, or, if the Online Calculator was used, a copy of the “Print Viewable Results” page(s) after completing use of the Online Calculator;
______ f. Proof of payment of Principal Amount and Lost Earnings or Restoration of Profits; and
______ g. If application concerns delinquent employee contributions or loan repayments, a statement from a Plan Official identifying the earliest date on which participant contributions/loan repayments reasonably could have been segregated from the employer’s general assets and supporting documentation on which the Plan Official relied?
______ 10. If you are an eligible applicant and wish to avail yourself of excise tax relief under the VFC Program Class Exemption:
_______a. Have you made proper arrangements to provide within 60 calendar days after submission of this application a copy of the Class Exemption notice to all interested persons and to the EBSA Regional Office to which the application is filed; or
_______b. If you are relying on the exception to the notice requirement in section IV.C. of the Class Exemption because the amount of the excise tax otherwise due would be less than or equal to $100.00, have you provided to the appropriate EBSA Regional Office a copy of a completed IRS Form 5330 or other written documentation containing the information required by IRS Form 5330 and proof of payment?
______ 11. In calculating Lost Earnings, have you elected to use:
______ a. The Online Calculator; or
______ b. A manual calculation performed in accordance with Section 5(b)?
______ 12. Where applicable, have you enclosed a description demonstrating proof of payment to participants and beneficiaries whose current location is known to the plan and/or applicant, and for individuals who need to be located, have you demonstrated how adequate funds have been segregated to pay missing individuals and commenced the process of locating the missing individuals using either the IRS and SSA locator services, or other comparable means?
______ 13. For purposes of the three transactions covered under Section 7.1 has the plan implemented measures to ensure that such transactions do not recur?
Signature of Applicant and Date Signed:
_________________________________________________________________________________
Name of Applicant: _________________________________________________________________
Title/Relationship to the Plan: ________________________________________________________
Name of Plan, EIN and Plan Number: _________________________________________________________________________________
| File Type | application/msword |
| File Title | Voluntary Fiduciary Correction Program |
| Author | OTIS |
| Last Modified By | OTIS |
| File Modified | 2008-05-15 |
| File Created | 2008-05-15 |