PDF document

- 1 -

Application for Voluntary OMB No. 1545-1673
For IRS Use Only
Form (Rev. November 2017)8950 Correction Program (VCP)
Department of the Treasury Under the Employee Plans Compliance Resolution System (EPCRS)
Internal Revenue Service ▶ Go to www.irs.gov/Form8950 for instructions and the latest information.
Review the attached Procedural Requirements Checklist before mailing this VCP submission to the IRS.
1a Name of plan sponsor (employer if single-employer plan)

1b Address of plan sponsor (if a P.O. box, see instructions) 1c City or town 1d State 1e ZIP code

1f Foreign country name 1g Foreign province/county 1h Foreign postal code

1i Employer identification number 1j Telephone number 1k Fax number 1l NAICS Business Code

2a Person to contact if more information is needed (see instructions).
(If a Power of Attorney is attached, check box and do not complete lines 2a through 2g.)

Name

2b Address 2c City or town 2d State 2e ZIP code

2f Telephone number 2g Fax number

If more space is needed for any line items, attach additional sheets of the same size as this form. Identify each additional sheet with
the plan sponsor’s name and EIN and identify the corresponding line item.

Under penalties of perjury, I declare that I have examined this VCP submission, including Form 8950 and all accompanying
documents, and, to the best of my knowledge and belief, they and the facts presented in support of this application and submission
are true, correct, and complete.

SIGN HERE ▶ Date ▶
This application must generally be signed by the owner of a sole proprietor or by
an officer with legal authority to bind a corporation, partnership, or organization.
For exceptions, see instructions under Who Must Sign.

Type or print name Type or print title

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 37769K Form 8950 (Rev. 11-2017)

- 2 -

Form 8950 (Rev. 11-2017)                                                                                        Page 2
3  Type of VCP submission (see instructions) 
   Check one:
   VCP regular submission

   VCP anonymous submission

   VCP group submission

   Non-VCP 457(b) submission (see instructions)

4a Name of plan:

4b Enter 3-digit plan number                 4d Enter the dollar value of the  
   (see instructions)                           plan’s assets (see instructions)

4c Enter month plan year ends                4e Enter number of participants 
   (MM) (see instructions)                      (see instructions)

5  Indicate type of plan by entering the corresponding number from the list below:   (Enter only one plan type.)

  01-Profit sharing (not 401(k))             11-SEP
  02-401(k)                                  12-SARSEP
  14-Stock bonus                             13-SIMPLE IRA
  03-Money purchase                          16-Group submission defined contribution
  06-Target benefit                          17-Group submission defined benefit
  04-Defined benefit (not cash balance or    99-Other (see instructions)
   other statutory hybrid)
  09-Cash balance or other statutory hybrid
  05-ESOP
  15-KSOP
  07-403(b)
  08-457(b)
  10-Governmental 414(d) defined benefit 
  20-Governmental 414(d) defined contribution

                                                                                     Form 8950 (Rev. 11-2017)

- 3 -

Form 8950 (Rev. 11-2017) Page 3
Yes No
6 Are all qualification failures and correction methods in this VCP submission being resolved by the use of
schedules specified on Forms 14568-A through 14568-I?
If “Yes,” please indicate the specific schedules you are submitting.
Form 14568-A, Sch 1 Form 14568-D, Sch 4 Form 14568-G, Sch 7
Form 14568-B, Sch 2 Form 14568-E, Sch 5 Form 14568-H, Sch 8
Form 14568-C, Sch 3 Form 14568-F, Sch 6 Form 14568-I, Sch 9

7 If you are proposing to correct any section 401(a) or section 403(b) qualification failure, does the correction
include a retroactive plan amendment? See instructions.

8 Has the plan or plan sponsor been party to an abusive tax avoidance transaction? See instructions.

If “Yes,” attach an explanation that provides details of the transaction (see instructions).

9 Does the VCP submission relate to the diversion or misuse of plan assets? See instructions.

10 As of the date this VCP submission is mailed to the IRS, is the plan sponsor or the plan under examination?

If “Yes,” you are ineligible for VCP (see instructions).

11 Have you previously filed a Form 5300 series determination letter application for this plan with the IRS that was
subsequently closed or withdrawn as a result of a failure to respond to a request for additional information?
If “Yes,” attach an explanation (see instructions).

Form 8950 (Rev. 11-2017)

- 4 -

Form 8950 (Rev. 11-2017) Page 4

Procedural Requirements Checklist

You do not have to use this checklist, but it may help prevent delayed IRS processing caused by an incomplete submission.

1 Is Form 8951, User Fee for Application for Voluntary Correction Program (VCP), under the Employee Plans Compliance
Resolution System (EPCRS), attached to Form 8950?
2 Is the appropriate user fee for your submission (and a photocopy of the user fee check) attached to Form 8951?

3 If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, and/or Form 8821, Tax Information
Authorization, attached? For more information, see the annual Employee Plans revenue procedure in effect at the time of
the submission.
4 Is the employer identification number (EIN) of the plan sponsor/employer (NOT the trust's EIN, or an individual's SSN)
entered on line 1i? See Line 1i in the instructions.
5 Is the application signed and dated? It generally must be signed by an authorized employee or the owner of the plan
sponsor. See Who Must Sign in the instructions for situations where the signer may be a different person.
6 If you are submitting Form 14568, Model VCP Compliance Statement, or any model document schedules using Forms
14568-A through 14568-I, have you used the latest official versions of these forms that are located at www.irs.gov/
Retirement-Plans/Correcting-Plan-Errors? The forms may not be modified in any way. See instructions.

7 If you answered “Yes” to line 7, have you included a copy of each corrective plan amendment?

8 If this is an anonymous VCP submission, have you included a signed statement from the plan sponsor's representative
indicating the representative has the legal authorization to make this submission and is willing and able to submit Form
2848 to the IRS upon disclosure of the taxpayer's identity? See instructions.

9 If this VCP submission involves an orphan plan, have you included appropriate documentation that establishes that this
submission is being made by an eligible party? See instructions.
10 Have you included an explanation of how and why the described qualification failures arose? Include a description of the
applicable administrative procedures for the plan that were in effect at the time the described failures occurred.
11 Have you included a complete description for each qualification failure that is to be resolved by this VCP submission? The
narrative description should include the years in which the failure occurred and the number of employees affected.

Note: If you answered “Yes” to line 6, then items 10 through 17 on this checklist do not apply as they have been incorporated into the
Form 14568 series (that is, Form 14568 and Forms 14568-A through 14568-I). All applicable items on each of the forms need to be
completed, and you must include the enclosure items listed on each applicable form with your VCP submission. The Form 14568
series may be used as a Model VCP Submission Compliance Statement. Forms 14568-A through 14568-I can be used to resolve
certain qualification failures. If you combine the model document schedules with the Form 14568, you must specify in each section of
Form 14568 the specific model schedules that are being submitted in that section.

Form 8950 (Rev. 11-2017)

- 5 -

Form 8950 (Rev. 11-2017) Page 5

Procedural Requirements Checklist (Continued)

12 Have you included a detailed description of the method for correcting the failures that the plan sponsor has implemented or
proposes to implement to correct each failure described in this VCP submission? Each step of the correction method must
be described in narrative form and must include specific information needed to support the proposed correction method.
See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.
13 Have you included a description of the administrative measures that have been or will be implemented to ensure that each
qualification failure described in this VCP submission does not recur? See the current EPCRS revenue procedure in effect
at the time the submission is made to the IRS.

14 For each failure involving corrective contributions or distributions, have you included an explanation that provides a detailed
narrative explaining the methodology you have used to determine lost earnings and how this is consistent with EPCRS
correction principles? See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.

15 For each failure involving corrective contributions or distributions, have you included detailed and 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. See the current EPCRS revenue procedure in effect at the
time the submission is made to the IRS.
16 For each failure involving participant loans that does not comply with section 72(p) requirements, have you included:
• An explanation that contains a detailed description of the failure;
• An explanation that requests income tax reporting relief, and/or a request to report the distribution on Form 1099-R in
the year of correction instead of the year of failure;
• For each case in which income tax reporting relief has been requested, detailed calculations and narrative that describe
the correction proposal and demonstrate compliance with the requirements set forth in the current EPCRS revenue
procedure in effect at the time the submission is made to the IRS?
17 For each operational failure that has resulted in certain excise taxes, have you included a request and supporting
explanation asking the IRS to waive or not pursue excise tax under section 4972, 4973, 4974, or 4979 or additional income
tax under section 72(t), as applicable? Where required, have you included detailed explanations supporting the request?
See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS for information as to
when such waivers are available.
18 Have you included an explanation that describes the method(s) used to locate and notify former employees or
beneficiaries? If there are no former employees or beneficiaries affected by the failure described in this VCP submission or
the proposed method of correction, have you provided an affirmative statement to that effect? See the current EPCRS
revenue procedure in effect at the time the submission is made to the IRS.
19 For each failure described in this VCP submission that includes a failure related to transferred assets, as defined in the
current EPCRS revenue procedure, have you included an attachment that describes the related employer transaction,
including the date of the employer transaction and the date the assets were transferred to the plan? See the current EPCRS
revenue procedure in effect at the time the submission is made to the IRS.
20 For operational failures, have you included a copy of the plan document (and adoption agreement, if applicable) or
applicable provisions of the plan document, that were in effect during the period of failure? See the current EPCRS revenue
procedure in effect at the time the submission is made to the IRS.

Form 8950 (Rev. 11-2017)

- 6 -

Form 8950 (Rev. 11-2017)                                                                                                   Page 6

                         Procedural Requirements Checklist (Continued)

21 For each failure described in this VCP submission that includes a non-amender failure other than a late interim amendment, 
   have you included a copy of the plan document in effect prior to any of the amendments used to correct the failure? See 
   the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.
22 For each failure being corrected by plan amendments or the adoption of a written plan, have you:
   • Included copies of the corrective amendments?
   • Submitted corrective documents that were executed by the plan sponsor (if correcting interim amendment failures or a 
   failure to adopt a written 403(b) plan timely)?
   • Included an explanation that identifies the specific plan language that resolves each specified qualification failure 
   described in the VCP submission (including the page and section of the plan document that includes the specific plan 
   language), if a restated plan document is being submitted as evidence of correction?
23 If the plan in this VCP submission is a 403(b) plan, has a written attachment been included that contains the following items?
   • A statement as to the type of employer (for example, a tax-exempt organization described in section 501(c)(3)) that is 
   making the VCP submission; and  
   • A statement indicating that the plan sponsor has contacted all other entities involved with the plan and has been 
   assured of cooperation to the extent necessary to implement the applicable correction.
24 If you wish to receive an acknowledgement letter that the IRS has received your Form 8950 and VCP submission, have you 
   included an IRS Letter 5265, Form 8950 Application for Voluntary Correction Program Acknowledgement Letter, with your 
   submission? See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.
25 Have you assembled your submission as described in the current EPCRS revenue procedure in effect at the time the 
   submission is made to the IRS?
26 Is this VCP submission limited to a minor modification to a previously issued compliance statement, as described in the 
   current EPCRS revenue procedure in effect at the time the submission is made to the IRS?
   If “Yes,” have you included the following items?
   • An attachment describing the modification;
   • A copy of the original compliance statement;
   • A copy of the original VCP submission;
   • Any other correspondence relating to the issuance of the original compliance statement, if applicable; and
   • An attachment indicating that the modification request is being mailed to the IRS before the end of the correction 
   period specified in the original compliance statement.

                                                                                                   Form 8950 (Rev. 11-2017)

PDF file checksum: 302546079

(Plugin #1/9.12/13.0)