Form 14568 Appendix C Part I Model VCP Submission Compliance Statem

Form

14568

(August 2016)

Department of the Treasury - Internal Revenue Service

Model VCP Compliance Statement

OMB Number
1545-1673

Include the plan name, Applicant’s EIN, and plan number on each page of the compliance statement, including attachments

Section I - Identifying Information
1. Applicant's name

2. Applicant's EIN (do not use SSN)

3. Plan number

4. Plan name

Section II - Applicant's Description of Failures
Attach additional pages, as needed. Label the attachment “Section II. Applicant’s Description of Failures.” List and
number each failure separately. If using the Form 14568 Schedules, specify the Schedule(s) that are included and attach
them to this compliance statement.

Section III - Applicant’s Description of the Proposed Method of Correction
Attach additional pages, as needed. Label the attachment “Section III. Applicant’s Description of the Proposed
Method of Correction.” Describe the correction method for each failure listed in Section II. If using the Form 14568
Schedules, specify the Schedule(s) that are included and attach them to this compliance statement.

Section IV - Applicant’s Proposed Procedures to Locate and Notify Former Employees or Beneficiaries
Attach additional pages, as needed. Label the attachment “Section IV. Applicant’s Proposed Procedures to Locate
and Notify Former Employees or Beneficiaries.” Describe the method(s) that will be used to locate and notify former
employees and beneficiaries, or provide an affirmative statement that no former employees or beneficiaries were affected
by each failure listed in Section II or will be affected by the correction methods described in Section III.

Section V - Applicant’s Proposed Revision to Administrative Procedures
Attach additional pages, as needed. Label the attachment “Section V. Applicant’s Proposed Revision to
Administrative Procedures.” Please include an explanation of how and why the failures arose and a description of the
measures implemented (or will be implemented) to ensure that the same failures do not occur in the future. If using the
Form 14568 Schedules, specify the Schedule(s) that are included and attach them to this compliance statement.

Section VI - Requests Related to Excise Taxes, Additional Tax, and Tax Reporting
The Applicant requests that the Internal Revenue Service (“Service”) not pursue the following taxes under the
Internal Revenue Code (“Code”) (attach supporting rationale)
Excise tax under Code section 4972 with respect to failure(s) number
Excise tax under Code section 4973 with respect to failure(s) number
Excise tax under Code section 4974 with respect to failure(s) number
Excise tax under Code section 4979 with respect to failure(s) number
Imposition of additional tax under Code section 72(t) with respect to failure(s) number

Catalog Number 66138J
www.irs.gov
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.

Form 14568 (Rev. 8-2016)

Page 2

Applicant's EIN (do not use SSN)

Plan number

Plan name

The Applicant requests that the Service grant the following for plan loan failures that did not comply with Code
section 72(p)
With respect to all loan(s) described in this compliance statement, that a deemed distribution corrected pursuant
to this VCP submission not be required to be reported on Form 1099-R and that repayments made by such
correction not result in the affected participant having additional basis in the plan for purposes of determining the
tax treatment of subsequent distributions from the plan.
With respect to all loan(s) described in this compliance statement, that a deemed distribution be reported on
Form 1099-R with respect to affected participant(s) for the year of correction instead of the year of the failure.
For one or more plan loan(s) described in this compliance statement that it be permitted to report the loan(s) as
deemed distributions in the year of correction instead of the year of the failure. For other affected plan loan(s),
the plan sponsor requests relief from reporting them as deemed distributions. Attach additional narrative details
that explain why the relief should be granted and which specific loans will be receiving what type of special
relief.

Section VII - Enforcement Resolution (to be completed by IRS only)
The Applicant will neither attempt to nor otherwise amortize, deduct, or recover from the Service any portion of the paid
user fee associated with this submission nor receive any Federal tax benefit on account of payment of such fee.
The Service will not pursue the sanction of revoking the tax-favored status of the plan under §§ 401(a), 403(b), 408(k), or
408(p) of the Internal Revenue Code (“Code”) on account of the failure(s) described in this compliance statement. This
compliance statement considers only the acceptability of the correction method(s) including the revision(s) of
administrative procedures described in the compliance statement and does not express an opinion as to the accuracy or
acceptability of any calculations or other materials included with or provided at any time during the processing of the VCP
submission. The reliance provided by this compliance statement is limited to the specific failures and years specified and
does not provide reliance for any other failure or year. In no event may this compliance statement be relied on for the
purposes of concluding that the Plan or plan sponsor was not a party to an abusive tax avoidance transaction. This
compliance statement should not be construed as affecting the rights of any party under any other law, including Title I of
the Employee Retirement Income Security Act of 1974.
This Agreement expresses no opinion as to whether the Plan otherwise satisfies the requirements of the Code and is not
a letter ruling within the meaning of Revenue Procedure 2016-1 (and subsequent successors) and Revenue Procedure
2016-4 (and subsequent successors) or a determination letter within the meaning of Revenue Procedure 2016-6 (and
subsequent successors).
This compliance statement is conditioned on (1) there being no misstatement or omission of material facts in connection
with the submission and (2) the completion of all corrections described in this compliance statement within one hundred
fifty (150) days of the date of this compliance statement.
The Service will treat the failure to adopt interim amendments or amendments for optional law changes, as described
in this compliance statement as if they had been adopted timely for the purpose of making available the extended
remedial amendment period set forth in Rev. Proc. 2007-44 and beginning on 1/1/2017 Rev. Proc. 2016-37, or its
successors. However, this compliance statement does not constitute a determination as to whether any such plan
amendments, as drafted, comply with the applicable changes in qualification requirements.
The Service will treat the failure to timely adopt a written plan, as required under the Code section 403(b), final Code
section 403(b) regulations and Notice 2009-3, as if it had been adopted timely for the purposes of making available
the extended remedial amendment period set forth in Announcement 2009-89, Rev. Proc. 2013-22 and any future
superseding guidance. However, this compliance statement does not constitute a determination as to whether the
written plan, as drafted, complies with the applicable requirements associated with Code section 403(b) and the final
Code section 403(b) regulations.

Catalog Number 66138J

www.irs.gov

Form 14568 (Rev. 8-2016)

Page 3

Applicant's EIN (do not use SSN)

Plan number

Plan name

With regard to failure number
(provided that no modification has been made to either the plan document or
adoption agreement of the plan that would otherwise cause the employer to lose reliance on the plan’s opinion or
advisory letter), the corrective amendment will not cause the plan to lose its status as a Master or Prototype plan or
Volume Submitter plan and (provided that no modification has been made that would otherwise affect the employer’s
eligibility for the six-year remedial amendment cycle) the employer will be allowed to remain within the six-year
remedial amendment cycle described in Revenue Procedure 2007-44, 2007-2, on a continuing basis until the
expiration of the next six-year remedial amendment cycle as provided in section 18.01 of Rev. Proc. 2007-44, or, if
different, the deadline announced by the Service, as provided in section 18.03 of that revenue procedure. In addition,
the issuance of this compliance statement constitutes a determination of the effect of the corrective plan amendment
on the qualification of the plan, and a subsequent filing of a determination letter request on such amendment will not
be required until the expiration of the next six-year remedial amendment cycle.
The Service will not pursue the following on account of the qualification failure(s) described in this submission:
Excise tax under Code section 4972.
Excise tax under Code section 4973.
Excise tax under Code section 4974.
Excise tax under Code section 4979.
With respect to the Overpayment failures described in this compliance statement that were corrected by
removing improper distributions from the IRA(s) of the affected participant(s) and returning those distributions to
the plan, the Service will not pursue
% of the 10% additional income tax under Code section 72(t).
A determination letter application, required by section 6.05 of Rev. Proc. 2013-12 (as modified by Rev. Proc.
2015-27) was included with this submission. This compliance statement is conditioned upon the issuance of a
favorable determination letter for the Plan as a result of determination letter application control number
.
If one or more of the failures described in this compliance statement are being corrected by proposed plan
amendments the Plan Sponsor may adopt such amendments by the later of: (a) one hundred fifty (150) days of the
date of the compliance statement or (b) ninety-one (91) days after the issuance of a favorable determination letter for
the application. For governmental plans within the meaning of Code section 414(d) the deadline to adopt these
amendments is further extended to the 91st day after the close of the first legislative session that begins more than
one hundred twenty (120) days after a favorable determination letter is issued for the application.
With respect to the loan failure(s) described in this compliance statement:
For all loan(s) that are corrected by a corrective repayment to the Plan or reamortization as described in this
compliance statement: The Service will not require deemed distributions under Code section 72(p) to be
reported on Form 1099-R with respect to the participant(s) affected by the failure(s), and repayments made
pursuant to the correction of such loan(s) will not result in an affected participant having additional basis in the
Plan for the purpose of determining the tax treatment of subsequent distributions from the Plan to such
participant(s).

Catalog Number 66138J

www.irs.gov

Form 14568 (Rev. 8-2016)

Page 4

Applicant's EIN (do not use SSN)

Plan number

Plan name

For all loan(s) that will be reported as deemed distributions. The Service will require deemed distributions under
Code section 72(p) to be reported on Form 1099-R with respect to the participant(s) affected by the failure(s).
However, the Plan will be permitted to report deemed distributions on Form 1099-R in the year of correction,
instead of the year of the failure.
If the requested relief is not applied consistently to all loans. For loan(s) where relief from issuing Form 1099-R
is applicable, all of the repayments made pursuant to the correction of such loan(s) will not result in an affected
participant having additional basis in the Plan for the purpose of determining the tax treatment of subsequent
distributions from the Plan to such participant(s). For all other loans (or situations where affected participants do
not choose to or may not qualify for Form 1099-R relief), the Service will require deemed distributions under
Code section 72(p) to be reported on Form 1099-R with respect to the participant(s) affected by the failure(s).
However, the Plan will be permitted to report the deemed distribution(s) on Form 1099-R in the year of
correction, instead of the year of the failure.

Approved:
Manager, Employee Plans Voluntary Compliance
Tax Exempt and Government Entities Division

Date:

Catalog Number 66138J

www.irs.gov

Form 14568 (Rev. 8-2016)