Department of the Treasury - Internal Revenue Service
  Form 14568-A                                                                                               OMB Number 
                      Model VCP Compliance Statement - Schedule 1: Interim 
  (November 2019)                                                                                            1545-1673
                                                Nonamender Failures
Include the plan name, Applicant’s EIN and plan number on each page of the compliance statement, including attachments
Plan name

EIN                                             Plan number

Instructions:

1. Schedule 1 can be used to report the correction of a failure to timely adopt interim amendments. A compliance statement issued for a 
  Schedule 1 failure results in the corrective amendment being treated as if it had been timely adopted for purposes of determining the 
  availability of the extended remedial amendment period. Thus, an Applicant may use Schedule 1 for the failure to adopt a required 
  interim amendment ONLY if the corrective amendment was adopted before the expiration of the plan’s extended remedial amendment 
  cycle (as determined under Rev. Proc. 2007-44 and after December 31, 2016, Rev. Proc. 2016-37) for that amendment. If the 
  corrective amendment was adopted after the expiration of the remedial amendment cycle, then the plan sponsor can use Form 
  14568-B, Model VCP Compliance Statement Schedule 2: Other Nonamender Failures and Failure to Adopt a 403(b) Plan Timely.

2. All corrective amendments required by Sections II and IV must be properly identified. Submit separate signed and dated 
  amendments. If the amendments are incorporated into a signed and dated restated document, the information in the VCP 
  submission must specify the page and section of the document that contains the amendment.
Section I - Identification of Failures
1. Were the amendments used to correct the failures under this Schedule 1 adopted before the expiration of the applicable extended 
  remedial amendment cycle
    Yes      No
  If “Yes,” proceed to line 2 of this Section I 
  If “No,” STOP - do NOT use this Schedule 1 
  In cases where late interim amendments are corrected after the expiration of the plan’s extended remedial amendment cycle, use 
  Form 14568-B, Model VCP Compliance Statement Schedule 2: Other Nonamender Failures and Failure to Adopt a 403(b) Plan 
  Timely.
2. Were the amendments adopted to correct the failure to timely adopt interim amendments
    Yes      No
  If “Yes,” proceed to line 3 of this Section I 
  If “No,” STOP - do NOT use this Schedule 1
3. The Applicant has indicated that the plan sponsor did not timely adopt amendments for the following: 
   
  (List each statutory, regulatory or other requirement for which the plan was not timely amended, and specify for each requirement the 
  published cumulative list in which the requirement appears and the location of the corrective amendment in the documents included 
  with the VCP submission (for example, by amendment number and paragraph number, or in the case of a restated plan, by page and 
  section number). Do not use a general statement referring only to a cumulative list or statute. For instance, the following description 
  would not be acceptable: “All interim amendments associated with the 20XX cumulative list [or the Pension Protection Act of 2006 
  (PPA)] were not timely adopted.”) 
  
  (Attach additional pages as needed. Label the attachment “Form 14568-A, Section I line 3 Identification of Interim Nonamender 
  Failures” and include the plan name, Applicant’s EIN and plan number on each page.)

Catalog Number 66144N                           www.irs.gov                                             Form 14568-A (Rev. 11-2019)
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.

                                                                                                                  Page 2
Plan name

EIN                                              Plan number

Section II - Description of Proposed Method of Correction
The plan sponsor has adopted amendments reflecting the items listed in Section I line 3 of this Schedule 1. These 
amendments are effective retroactive to the effective dates of the specific provisions contained in the amendments. The 
signed and dated amendments have been enclosed with this VCP submission.
Section III - Change in Administrative Procedures
The Applicant has taken (or will take) the following steps to ensure that the failures will not recur

Section IV - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor 
encloses copies of the signed and dated amendments used to correct the failures identified in Section I line 3 of this 
Schedule 1 with this VCP submission.

Catalog Number 66144N               www.irs.gov                         Form 14568-A (Rev. 11-2019)