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Employee Benefits Security Administration

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> EBSA > Compliance
Assistance > VFCP Checklist

VFCP Checklist

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Use this checklist to ensure that you are submitting a
complete Voluntary Fiduciary Correction Program (VFCP) 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.

__Yes __No __N/A

Have you reviewed the eligibility, definitions,
transaction and correction, and documentation sections of the VFCP?

__Yes __No __N/A

Have you included the name, address and telephone number
of a contact person familiar with the contents of the application?

__Yes __No __N/A

Have you provided the EIN, Plan Number, and address of
the plan sponsor and plan administrator?

__Yes __No __N/A

Have you provided the date that the most recent Form 5500
was filed by the plan?

__Yes __No __N/A

Have you enclosed a signed and dated certification under
penalty of perjury for each applicant and the applicant’s representative,
if any?

__Yes __No __N/A

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?

__Yes __No __N/A

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?

__Yes __No __N/A

Where applicable, have you enclosed a copy of an
appraiser’s report?

__Yes __No

Have you enclosed supporting documentation, including:

__Yes __No __N/A

A detailed narrative of the Breach, including the
date it occurred;

__Yes __No __N/A

Documentation that supports the narrative
description of the transaction;

__Yes __No __N/A

An explanation of how the Breach was corrected, by
whom and when, with supporting documentation;

__Yes __No __N/A

A list of all persons materially involved in the
Breach and its correction (e.g., fiduciaries, service providers,
borrowers, lenders);

__Yes __No __N/A

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” pages(s) after completing use of the Online Calculator;
and

__Yes __No __N/A

Proof of payment of Principal Amount and Lost
Earnings or Restoration of Profits; and.

__Yes __No __N/A

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?

__Yes __No __N/A

If you are an eligible applicant and wish to avail
yourself of excise tax relief under the VFCP Class Exemption:

__Yes __No __N/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

__Yes __No __N/A

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?

__Yes __No __N/A

In calculating Lost Earnings, have you elected to use:

__Yes __No __N/A

The Online Calculator; or

__Yes __No __N/A

A manual calculation performed in accordance with
Section 5(b)?

__Yes __No __N/A

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 described how adequate funds
have been segregated to pay missing individuals and commenced the process
of locating the missing participants individuals using either the IRS and
SSA locator services, or other comparable means?

__Yes __No __N/A

For purposes of the three transactions covered under
Section 7.1 has the plan implemented measures to ensure that such
transactions do not recur?

Name of
Applicant

Signature of
Applicant and Date Signed

Title/Relationship to the Plan

Name of Plan,
EIN and Plan
Number

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 must complete this
form and submit it as part of the application 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 that you have satisfied the requirements of the
Program. EBSA estimates that completing and submitting this form will
require an average of 2 to 4 minutes. 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.

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