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

Department of the Treasury - Internal Revenue Service

Form 14568-H
(August 2016)

Model VCP Compliance Statement - Schedule 8:
Failure to Pay Required
Minimum Distributions Timely

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 (DO NOT USE THIS FORM IF ANY PARTICIPANT IS DECEASED OR
THE FAILURE INVOLVES A BENEFICIARY OR IF BENEFITS WERE NOT PAID OUT TIMELY AT
NORMAL RETIREMENT AGE. IF YOU CANNOT USE THIS FORM, ATTACH A WRITTEN NARRATIVE TO
FORM 14568 AND PROVIDE THE NECESSARY INFORMATION REQUESTED BY THAT FORM)
The plan identified above did not comply with the requirements of section 401(a)(9) of the Internal Revenue Code (Code)
as required minimum distributions (RMD) were not paid out in a timely manner or were less than what was required.
When completing this table, affected plan participants should be counted separately under each year that an RMD was
not made and not just in the first year of the failure.
Calendar Years

Number of Participants
Affected

Total Amount of Missed Required Minimum Distributions
(Do Not Include Earnings)

Section II - Description of the Proposed Method of Correction
Defined Contribution plan only - The plan will distribute the required minimum distributions (adjusted for earnings
from the date of the failure to the date of distribution) to affected participants. For each affected participant, the
required minimum distribution amount 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 section 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. Earnings will be determined as follows:

Defined Benefit plan only - The plan will distribute the required minimum distributions plus an additional
payment representing the loss of use of such amounts. (Note the additional payment is determined in
accordance with the plan’s written terms for actuarial equivalence). The additional payment is determined as
follows:

Catalog Number 66153Y
www.irs.gov
For Paperwork Reduction Act information see current EPCRS Revenue Procedure.

Form 14568-H (Rev. 8-2016)

Page 2

Plan name

EIN

Plan number
Defined Benefit plan only – At the time of the proposed correction is the plan subject to any restriction on lump
sum payments under Code section 436(d)? Include a copy of the plan’s most current actuarial certification of the
plan’s Adjusted Funded Target Attainment Percentage (AFTAP) if “No” is checked.
Yes No
If yes, the plan sponsor will contribute to the plan, at the time of correction, an amount equal to the corrective
distribution mentioned in this compliance statement as discussed in the current EPCRS revenue procedure.

Section III - Request for Relief
A. The Applicant requests relief with regard to excise taxes under section 4974 of the Code
Yes No
At least one affected participant is either an owner-employee (see section 401(c)(3) of the Code) 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 section 4974 excise tax:

Section IV - Change in Administrative Procedures
Include an explanation of how and why the failures arose and a description of the measures that have been (or 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:
• A detailed explanation as to how you determined the user fee for this submission. If you qualify for a reduced fee, be
sure to include the total number of plan participants with RMD failures. Note the reduced user fee does not apply if the
RMD failure involves deceased plan participants, plan beneficiaries or situations where plan benefits were not paid out in
a timely manner at the plan’s normal retirement age.
• 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 proposed correction method.
• 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.
• For defined contribution plans, the calculations must show how earnings were determined and their impact on the
calculation of the corrective distributions.
• For defined benefit plans only, a copy of the plan’s most current AFTAP certification if the Applicant has indicated that
the plan is not under IRC 436(d) restrictions.
Catalog Number 66153Y

www.irs.gov

Form 14568-H (Rev. 8-2016)