Department of the Treasury - Internal Revenue Service
Form 14568                                                                                    OMB Number 
                                                                                              1545-1673
(July 2023)           Model VCP Compliance Statement

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. Be sure to include the plan name, Applicant’s EIN, and plan number on each page of the 
attachment. If using the Form 14568 Schedules, specify the Schedules 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. Be sure to include the plan 
name, Applicant’s EIN, and plan number on each page of the attachment. If using the Form 14568, Schedules, specify the 
Schedules 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 methods 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. Be sure to include 
the plan name, Applicant’s EIN, and plan number on each page of the attachment

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.” Include an explanation of how and why the failures arose and a description of the 
measures implemented (or that will be implemented) to ensure that the same failures won’t recur. Be sure to include the 
plan name, Applicant’s EIN, and plan number on each page of the attachment. If using the Form 14568 Schedules, 
specify the Schedules 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 (IRS) not pursue the following taxes under the Internal 
Revenue Code (IRC) (attach supporting rationale)
     Excise tax under IRC Section 4972 with respect to failures number
     Excise tax under IRC Section 4973 with respect to failures number
     Excise tax under IRC Section 4974 with respect to failures number
     Excise tax under IRC Section 4979 with respect to failures number
     Imposition of additional tax under IRC Section 72(t) with respect to failures number

Catalog Number 66138J                           www.irs.gov                              Form 14568 (Rev. 7-2023)
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.

                                                                                                                 Page 2
Applicant’s EIN (do not use SSN)                          Plan number

Plan name

The Applicant requests that the IRS grant the following for plan loan failures that did not comply with IRC 
Section 72(p)
      With respect to all loans described in this compliance statement, that a deemed distribution corrected pursuant 
      to this VCP submission is not required to be reported on Form 1099-R and that repayments made by the 
      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 loans described in this compliance statement, that a deemed distribution be reported on Form 
      1099-R with respect to affected participants for the year of correction instead of the year of the failure
      For one or more plan loans described in this compliance statement, that it be permitted to report the loans as 
      deemed distributions in the year of correction instead of the year of the failure. For other affected plan loans, 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 and plan sponsor will neither attempt to nor otherwise amortize, deduct, or recover from the IRS any portion 
of the paid user fee associated with this submission nor receive any federal tax benefit on account of payment of the fee. 
The IRS will not pursue revocation of the tax-favored status of the plan under IRC Section 401(a), 403(b), 408(k) or 408(p) 
on account of the failures described in this compliance statement. This compliance statement considers only the 
acceptability of the correction methods including the revisions 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 compliance statement expresses no opinion as to whether the plan otherwise satisfies the requirements of the IRC 
and is not a letter ruling or a determination letter within the meaning of Revenue Procedure (Rev. Proc.) 2023-1 (updated 
annually) and Rev. Proc. 2023-4 (updated annually). 
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 150 days of the 
date of this compliance statement. For governmental plans within the meaning of IRC Section 414(d), corrective plan 
amendments required by this compliance statement that fix the operational failures or employer eligibility failure described 
in this compliance statement, must be adopted by the later of 150 days after the date of this compliance statement or the 
close of the first regular legislative session of the legislative body with the authority to amend the plan that begins on or 
after 91 days after the date of this compliance statement.

The IRS will treat the failure to adopt interim amendments, 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 January 1, 2017, Rev. Proc. 2016-37, or its successors. However, this compliance 
statement does not constitute a determination as to whether the plan amendments, as drafted, comply with the 
applicable changes in qualification requirements

The IRS will treat the failure to timely adopt a written plan, as required under the IRC Section 403(b), Final Treasury 
Regulations under IRC Section 403(b) 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, 
Rev. Proc. 2017-18, Rev. Proc. 2019-39, Notice 2020-35, Rev. Proc. 2021-37, Rev. Proc. 2022-40, and any future 
superseding guidance. However, this compliance statement doesn’t constitute a determination as to whether the 
written plan, as drafted, complies with the applicable requirements associated with IRC Section 403(b) and the Final 
Treasury Regulations under IRC Section 403(b)

Catalog Number 66138J                               www.irs.gov      Form 14568 (Rev. 7-2023)

                                                                                                                    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 pre-approved IRC Section 
    401(a) or pre-approved IRC Section 403(b) 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 Rev. Proc. 2016-37 (and any future superseding 
    guidance) for IRC Section 401(a) plans or Rev. Proc. 2013-22 and Rev. Proc. 2021-37 (and any future superseding 
    guidance) for IRC Section 403(b) plans on a continuing basis until the expiration of the next six-year remedial 
    amendment cycle as provided in Section 16.01 of Rev. Proc. 2016-37 or Section 10 of Rev. Proc. 2019-39 (and any 
    future superseding guidance)
    The IRS will not pursue the following on account of the qualification failures described in this submission:
         Excise tax under IRC Section 4972
         Excise tax under IRC Section 4973
         Excise tax under IRC Section 4974
         Excise tax under IRC Section 4979
         With respect to the overpayment failures described in this compliance statement that were corrected by 
         removing improper distributions from the IRAs of the affected participants and returning those distributions to the 
         plan, the 10% additional tax under IRC Section 72(t)
    With respect to the loan failures described in this compliance statement:
         For all loans that are corrected by a corrective repayment to the plan or reamortization as described in this 
         compliance statement. The IRS will not require deemed distributions under IRC Section 72(p) to be reported on 
         Form 1099-R with respect to the participants affected by the failures, and repayments made pursuant to the 
         correction of the loans 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 the participants

         For all loans that will be reported as deemed distributions. The IRS will require deemed distributions under IRC 
         Section 72(p) to be reported on Form 1099-R with respect to the participants affected by the failures. 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 loans where relief from issuing Form 1099-R is 
         applicable, all repayments made pursuant to the correction of the loans 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 the participants. For all other loans (or situations where affected participants do not choose to or 
         may not qualify for Form 1099-R relief), the IRS will require deemed distributions under IRC Section 72(p) to be 
         reported on Form 1099-R with respect to the participants affected by the failures. However, the plan will be 
         permitted to report the deemed distributions 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. 7-2023)