14568-F Appendix C Part II Schedule 6 Employer Eligibility Failu

Department of the Treasury - Internal Revenue Service

Form 14568-F
(January 2014)

Appendix C Part II Schedule 6
Employer Eligibility Failure
(§ 401(k) and 403(b) Plans only)

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
The following failure occurred with respect to the plan identified above (check failure that applies)
403(b) Plans
The plan was intended to satisfy the requirements of § 403(b) but was adopted by a Plan Sponsor that was not a tax-exempt
organization described in § 501(c)(3) or a public educational organization described in § 170(b)(1)(A)(ii).
The type of organization sponsoring the Plan during the period of the failure was:

The failure occurred during the following plan year(s):
Section 401(k) Plans
The plan was intended to include a qualified cash or deferred arrangement and satisfy the requirements of §§ 401(a) and 401(k)
but was adopted by an employer that failed to meet the eligibility requirements to establish a § 401(k) Plan.
Describe why the employer was ineligible to maintain the § 401(k) plan:

Section II - Description of Proposed Method of Correction
Section 403(b) Plans
1. All contributions under the plan ceased as of
submission was filed with the Service.)

. (Insert date beginning no later than the date the VCP

2. No new employee or employer contributions will be permitted in the future.
3. The assets in the plan will remain in the trust, annuity contract, or custodial account and will be distributed no earlier than the
occurrence of one of the permitted events under § 403(b)(7) or § 403(b)(11).
Section 401(k) Plans
1. All contributions under the plan ceased as of
submission was filed with the Service.)

. (Insert date beginning no later than the date the VCP

2. No new employee or employer contributions will be permitted in the future.
3. The assets in the plan will remain in the trust, annuity contract, or custodial account and will be distributed no earlier than the
occurrence of one of the permitted events under § 401(k).

Section III - 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.

Catalog Number 66150R
www.irs.gov
For Paperwork Reduction Act information see Revenue Procedure 2013-12.

Form 14568-F (1-2014)