14568-I Appendix C Part II Schedule 9 Correction by Plan Amendme

Department of the Treasury - Internal Revenue Service

Form 14568-I
(January 2014)

Appendix C Part II Schedule 9
Correction by Plan Amendment
(in accordance with Appendix B)

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(s) and Proposed Method(s) of Correction
The following failure(s) occurred with respect to the plan identified above (check failure(s) that apply)
A. § 401(a)(17) Failure in a Defined Contribution Plan (check as applicable)
Contributions
Forfeitures
were allocated on the basis of compensation in excess of the limit under § 401(a)(17) as provided below:
Enter the plan years in which the failure occurred, the amount of the allocations in excess of § 401(a)(17) made for each plan year
(including Earnings), and the number of participants affected by the failure for each plan year:
Plan Year

Amounts Allocated in Excess of § 401(a)(17)

Number of Participants Affected

Description of Proposed Method of Correction:
An additional amount has been (or will be) contributed to the plan on behalf of each of the employees who received an allocation
for the year of the failure (excluding each employee for whom there was a § 401(a)(17) failure). The amount contributed for an
employee is equal to the employee's plan compensation for the year of the failure multiplied by a fraction, the numerator of which is
the improperly allocated amount made on behalf of the employee with the largest improperly allocated amount, and the
denominator of which is the limit under § 401(a)(17) applicable to the year of the failure. In addition, the plan will be retroactively
amended to reflect the increased contribution and allocation percentages for the plan’s participants.
Enter the plan years in which the failure occurred, the fraction used to determine the additional amount allocated to employees
other than those for whom there was a § 401(a)(17) failure, and the total required contribution (before adjusting for Earnings) for
each plan year in which the failure occurred:
Plan Year

Fraction Used to Determine the
Additional Amount Allocated

Catalog Number 66156F
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For Paperwork Reduction Act information see Revenue Procedure 2013-12.

Total Required Contribution
(Before Adjusting for Earnings)

Form 14568-I (1-2014)

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Plan name

EIN

Plan number

The resulting additional amount will be adjusted for Earnings from the end of the plan year in which the failure occurred through the
date of the corrective contribution. The method for determining the Earnings adjustment is as follows:

Former employees affected by the failure (check one):
There are no former employees affected by the failure.
Affected former employees (or if deceased, their estate or known beneficiary) will be contacted and contributions will be made
to the plan on their behalf. To the extent that an affected former employee or beneficiary cannot be located following a mailing
to the last known address, the Plan Sponsor will take the actions specified below to locate that employee or beneficiary:

After such actions are taken, if an affected employee or beneficiary is not found but is subsequently located on a later date, the
Plan Sponsor will make corrective contributions on behalf of the affected employee at that time.
B. Hardship Distribution Failure
Hardship distributions were made to participants under the plan. All plan participants were entitled to request hardship distributions,
and all requests were evaluated in accordance with uniform eligibility standards, as described below:

Enter the plan years in which the failure occurred, the number of hardship distributions made for each plan year, and the number
and amount of distributions made to highly compensated employees (HCEs) and nonhighly compensated employees (NHCEs)
respectively, affected by the failure for each plan year.
Plan
Year

Number of Hardship
Distributions Made
During the Plan Year

Number of Hardship
Distributions Made to
NHCEs

Amount of
Distributions

Number of Hardship
Distributions Made to
HCEs

Amount of
Distributions

Description of the Proposed Method of Correction:
The failure was (or will be) corrected by retroactively amending the plan to provide for the hardship distributions that were made
available. The effective date of the corrective amendment is:
Catalog Number 66156F

www.irs.gov

Form 14568-I (1-2014)

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Plan name

EIN

Plan number

C. Plan Loan Failure
Plan loans were made to participants under the plan. All plan participants were entitled to request plan loans under uniform
standards of eligibility, and all plan loans made satisfied the requirements of § 72(p).
Enter the plan years in which the failure occurred, the number of participant plan loans made for each plan year, and the number
and amount of plan loans made to highly compensated employees (HCEs) and nonhighly compensated employees (NHCEs)
respectively, affected by the failure for each plan year.
Plan
Year

Number of Plan Loans
Made During the Plan Year

Number of Plan Loans
Made to NHCEs

Amount of Plan
Loans

Number of Plan Loans
Made to HCEs

Amount of Plan
Loans

Description of the Proposed Method of Correction:
The failure was (or will be) corrected by retroactively amending the plan to provide for the plan loans that were made available. The
effective date of the corrective amendment is:
D. Early Inclusion of Otherwise Eligible Employee Failure
Employees: (check applicable boxes)
Who had not satisfied the plan’s minimum age or service requirements were treated as eligible participants on a date prior to
their being eligible under the plan and were entitled to the same benefits under the plan to which they would have been
entitled had they completed the minimum age or service requirements of the plan.
Who had completed the plan’s minimum age or service requirements were treated as eligible participants prior to the
applicable plan entry date and were entitled to the same benefits under the plan to which they would have been entitled had
they entered the plan timely.
The plan’s minimum age or service requirements and plan entry date, as applicable, for the years of the failure were as follows:

Enter the plan years in which the failure occurred and the number of participants affected by the failure, broken down by type of
employee (highly compensated employee (HCE) or nonhighly compensated employees (NHCE) respectively, for each plan year.
Plan Year

Number of NHCEs Affected by
the Failure During the Plan Year

Number of HCEs Affected by
the Failure During the Plan Year

Description of the Proposed Correction Method:
The failure was (or will be) corrected by retroactively amending the plan to provide for the inclusion of the ineligible employees. The
effective date of the corrective amendment is:
Catalog Number 66156F

www.irs.gov

Form 14568-I (1-2014)

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Plan name

EIN

Plan number

Section II - 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 III - 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:
● Copies of all amendments used to correct the failure(s), either as adopted or in proposed form. (required)
● A copy of the plan document in effect prior to any of the amendments used to correct the failure(s). (required)
● For a § 401(a)(17) failure in a defined contribution plan, 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 example, the determination of the fraction used to determine the additional amount to be allocated to each
employee (other than those for whom there was a § 401(a)(17) failure) must be demonstrated.

Catalog Number 66156F

www.irs.gov

Form 14568-I (1-2014)