14568-H Appendix C Part II Schedule 8 Failure to Pay Required Mi

Department of the Treasury - Internal Revenue Service

Form 14568-H

Appendix C Part II Schedule 8

(January 2014)

Failure to Pay Required Minimum Distributions
Timely under § 401(a)(9)

OMB Number
1545-1673

Please include the plan name, Applicant’s EIN, and plan number information on each page of the submission
Plan name

EIN

Plan number

Section I - Identification of Failure
Calendar Years

Number of Participants Affected

Total Amount of Missed Required Minimum Distributions

Section II - Description of the Proposed Method of Correction
Defined Contribution plan only - The plan will distribute the required minimum distributions (with Earnings from the date of the
failure to the date of distribution) to affected participants. For each affected participant, the amount to be distributed for each year in
which the failure occurred will be determined by dividing the adjusted account balance on the applicable valuation date by the
applicable distribution period. For this purpose, adjusted account balance means the actual account balance, determined in
accordance with § 1.401(a)(9)-5 Q&A-3 of the Income Tax Regulations, reduced by the amount of the total missed minimum
distributions for prior years.
Defined Benefit plan only - The plan will distribute the required minimum distributions plus an interest payment representing
the loss of use of such amounts. The interest adjustment is determined as follows:

Section III - Request for Relief
A. The Applicant requests relief with regard to excise taxes under § 4974
Yes

No
At least one affected participant is either an owner-employee (see § 401(c)(3)) or, if the Plan Sponsor is a
corporation, a 10 percent owner of such corporation.

If “Yes,” the Applicant submits the following explanation for its request for relief from the § 4974 excise tax:

Catalog Number 66153Y
www.irs.gov
For Paperwork Reduction Act information see Revenue Procedure 2013-12.

Form 14568-H (1-2014)

Page 2
Plan name

EIN

Plan number

Section IV - Change in Administrative Procedures
Please include an explanation of how and why the failures arose and a description of the measures that will be implemented to ensure
that the same failures will not recur.

Section V - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the Plan Sponsor encloses the
following with this submission:
Specific calculations for each affected employee or a representative sample of affected employees. (The sample calculations must be
sufficient to demonstrate each aspect of the correction method proposed. For a defined benefit plan, these specific calculations must
illustrate the interest rate used to represent the loss of the use of the missed required minimum distributions.)

Catalog Number 66153Y

www.irs.gov

Form 14568-H (1-2014)