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VFCP = Checklist
Use this checklist to ensure that you are = submitting a=20 complete Voluntary Fiduciary Correction Program (VFCP) = application. The=20 applicant must sign and date the checklist and include it with the = application. Indicate =91=91Yes=92=92, =91=91No=92=92 or = =91=91N/A=92=92 next to each item. A=20 =91=91No=92=92 answer or the failure to include a completed = checklist will delay=20 review of the application until all required items are = received. | ||||||||||||||
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__Yes __No __N/A |
Have you reviewed the eligibility, definitions, = transaction and correction, and documentation sections of the = VFCP?=20 | |||||||||||||
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__Yes __No __N/A |
Have you included the name, address and = telephone number=20 of a contact person familiar with the contents of the application? = | |||||||||||||
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__Yes __No __N/A |
Have you provided the EIN, Plan Number, and = address of=20 the plan sponsor and plan administrator? | |||||||||||||
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__Yes __No __N/A |
Have you provided the date that the most recent = Form 5500=20 was filed by the plan? | |||||||||||||
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__Yes __No __N/A |
Have you enclosed a signed and dated = certification under=20 penalty of perjury for each applicant and the applicant=92s = representative,=20 if any? | |||||||||||||
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__Yes __No __N/A |
Have you enclosed relevant portions of the plan = document=20 and any other pertinent documents (such as the adoption agreement, = trust=20 agreement, or insurance contract) with the relevant sections = identified?=20 | |||||||||||||
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__Yes __No __N/A |
If applicable, have you provided written = notification to=20 EBSA of any current investigation or examination of the plan, or = of the=20 applicant or plan sponsor in connection with an act or transaction = directly related to the plan by the PBGC, any state attorney = general, or=20 any state insurance commissioner? | |||||||||||||
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__Yes __No __N/A |
Where applicable, have you enclosed a copy of = an=20 appraiser=92s report? | |||||||||||||
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__Yes __No |
Have you enclosed supporting documentation, = including:=20 | |||||||||||||
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__Yes __No __N/A |
If you are an eligible applicant and wish to = avail=20 yourself of excise tax relief under the VFCP Class Exemption: = | |||||||||||||
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__Yes __No __N/A |
In calculating Lost Earnings, have you elected = to use:=20 | |||||||||||||
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__Yes __No __N/A |
Where applicable, have you enclosed a = description=20 demonstrating proof of payment to participants and beneficiaries = whose=20 current location is known to the plan and/or applicant, and for=20 individuals who need to be located, have you described how = adequate funds=20 have been segregated to pay missing individuals and commenced the = process=20 of locating the missing participants individuals using either the = IRS and=20 SSA locator services, or other comparable means? | |||||||||||||
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__Yes __No __N/A |
For purposes of the three transactions covered = under=20 Section 7.1 has the plan implemented measures to ensure that such=20 transactions do not recur? | |||||||||||||
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Paperwork Reduction Act Notice - The = information=20 identified on this form is required for a valid application for = the=20 Voluntary Fiduciary Correction Program of the U.S. Department of = Labor=92s=20 Employee Benefits Security Administration (EBSA). You must = complete this=20 form and submit it as part of the application in order to receive = the=20 relief offered under the Program with respect to a breach of = fiduciary=20 responsibility under Part 4 of Title I of ERISA. EBSA will use = this=20 information to determine that you have satisfied the requirements = of the=20 Program. EBSA estimates that completing and submitting this form = will=20 require an average of 2 to 4 minutes. This collection of = information is=20 currently approved under OMB Control Number 1210-0118. You are not = required to respond to a collection of information unless it = displays a=20 currently valid OMB Control Number. = |
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