Department of the Treasury - Internal Revenue Service
Form 14568-I                                                                                      OMB Number 
                             Model VCP Compliance Statement - Schedule 9:
(September 2017)                                                                                  1545-1673
                      Limited Safe Harbor Correction by Plan Amendment

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

EIN                                                      Plan number

Section I - Identification of Failure(s) and Proposed Method(s) of Correction
The following failure(s) to comply with the Internal Revenue Code (IRC) occurred with respect to the plan identified above 
(check failure(s) that apply)
A. IRC Section 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 IRC Section 401(a)(17) as provided below
Enter the plan years in which the failure occurred, the amount of the allocations in excess of IRC Section 401(a)(17) 
made for each plan year (adjust for earnings), and the number of participants affected by the failure for each plan 
year:
                             Amounts Allocated in Excess of  
    Plan Year                                                               Number of Participants Affected
                             IRC Section 401(a)(17)

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 IRC Section 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 IRC Section 
401(a)(17) applicable to the year of the failure. In addition, the plan will be retroactively amended by the plan sponsor 
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 IRC Section 401(a)(17) failure, and the total required contribution 
(before adjusting for earnings) for each plan year in which the failure occurred:
                             Fraction Used to Determine the                       Total Required Contribution  
    Plan Year
                             Additional Amount Allocated                    (Before Adjusting for Earnings)

Catalog Number 66156F                        www.irs.gov                                     Form 14568-I (Rev. 9-2017)
For Paperwork Reduction Act information see current EPCRS Revenue Procedure.

                                                                                                                 Page 2
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 (Attach additional pages as needed. Label the attachment “Section IA of Form 14568-I, Description of the 
Proposed Method of Correction-Earnings” and include the plan name, Applicant’s EIN and plan number at the top of 
each page).

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 located at 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 even though the written terms of the plan did not 
provide for any hardship distributions. All plan participants were entitled to request hardship distributions, and all 
requests were evaluated in accordance with uniform eligibility standards, as described below.

Catalog Number 66156F                   www.irs.gov            Form 14568-I (Rev. 9-2017)

                                                                                                                  Page 3
Plan name

EIN                                                     Plan number

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.
                      Number of Hardship 
                                         Number of Hardship                Number of Hardship 
                      Distributions Made                        Amount of                           Amount of  
    Plan Year                            Distributions Made                Distributions Made 
                      During the Plan                       Distributions                           Distributions
                                         to NHCEs                                 to HCEs
                      Year

Description of the Proposed Method of Correction 
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the 
hardship distributions that were made available. The effective date of the corrective amendment is                          .

C. Plan Loan Failure
Plan loans were made to participants under the plan even though the written terms of the plan did not provide for any 
participant loans. All plan participants were entitled to request plan loans under uniform standards of eligibility and all 
plan loans made satisfied the requirements of IRC Section 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 HCEs and NHCEs respectively, affected by the failure for each plan 
year.
                      Number of Plan     Number of Plan                           Number of Plan 
                                                            Amount of Plan                          Amount of 
    Plan Year         Loans Made During  Loans Made to                            Loans Made to 
                                                                Loans                               Plan Loans
                      the Plan Year      NHCEs                                    HCEs

Description of the Proposed Method of Correction 
The failure was (or will be) corrected by having the plan sponsor retroactively amend 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.

Catalog Number 66156F                    www.irs.gov                                   Form 14568-I (Rev. 9-2017)

                                                                                                                  Page 4
Plan name

EIN                                                Plan number

    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

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

                      Number of NHCEs Affected by                  Number of HCEs Affected by  
    Plan Year
                      the Failure During the Plan Year             the Failure During the Plan Year

Description of the Proposed Correction Method 
The failure was (or will be) corrected by having the plan sponsor retroactively amend the plan to provide for the 
inclusion of the ineligible employees. The effective date of the corrective amendment is                            .

Section II - Change in Administrative Procedures
Include an explanation of how and why the failures arose and a description of the measures that will be (or have 
been) implemented to ensure that the same failures will not recur.

Catalog Number 66156F                              www.irs.gov                           Form 14568-I (Rev. 9-2017)

                                                                                                                 Page 5
Plan name

EIN                                                  Plan number

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 an IRC Section 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 an IRC 
    Section 401(a)(17) failure) must be demonstrated.
●  For Early Inclusion of Otherwise Eligible Employee Failure, submit a demonstration or analysis that 
    o Establishes that the corrective amendment is non-discriminatory under IRC Section 401(a)(4). Only include this 
         item if HCEs benefited from the corrective plan amendment.  
    o Proves the early inclusion of otherwise eligible employees did not result in an IRC Section 411(d)(6) cutback for 
         the plan’s other participants.

Catalog Number 66156F                       www.irs.gov              Form 14568-I (Rev. 9-2017)