CYCLE A Submission Period – 02/01/2016 – 01/31/2017

Employee                                                  Explanation No. 4

Benefit                                                   Miscellaneous

                                                          Provisions
Plans

Note:                                                     The purpose  of Form 5626, Worksheet Number 4 and this 
                                                          explanation is to identify major problems in various areas of 
Plans submitted during the Cycle A submission period      a plan. However, there may be issues not mentioned in the 
must satisfy the applicable changes in plan qualification worksheet  that  could  affect  the  plan’s  qualification.  A  plan 
requirements listed in Section IV of Notice 2015-84,      which generally is more generous than the statutory minimum 
2014-52 I.R.B. 1(the 2015 Cumulative List).               requirement for qualification in any given area will not fail to 
                                                          qualify merely because it fails to adhere to specific language 
                                                          found in the statute if it can be otherwise demonstrated that 
This publication contains copies of:                      the minimum statutory requirement is met.
Form 5626, Worksheet 4
Form 6043, Deficiency Checksheet 4                        Generally, a “Yes” answer to a question on the worksheet in-
                                                          dicates a favorable conclusion while a “No” answer signals 
These forms are included as examples only and should      a  problem  concerning  plan  qualification.  This  rule  may  be 
not be completed and returned                             altered by specific instructions for a given question. Please 
to the Internal Revenue Service.                          explain any “No” answer in the space provided on the work-
                                                          sheet.

                                                          The sections cited at the end of each paragraph of explana-
                                                          tion are to the Internal Revenue Code and the Income Tax 
                                                          Regulations.

                                                          The technical principles in this publication may be changed 
                                                          by future regulations or guidelines.

Publication 6392 (Rev. 4-2016)  Catalog Number 48727K  Department of the Treasury  Internal Revenue Service  www.irs.gov

Page 2                                                                  CYCLE A Submission Period – 02/01/2016 – 01/31/2017

I. Mergers and Termination Provisions

Line a. A qualified plan must contain an express provision that if it terminates, or partially terminates (or, in the case of a profit-sharing, 
stock bonus, or other plan described in section 412(h), there is a complete discontinuance of contributions), a participant’s interest under 
the plan on the date of termination (or discontinuance) is nonforfeitable to the extent funded. Rev. Rul. 2007-43, 2007-28 I.R.B. 45, states 
that there is a rebuttable presumption that a partial termination has occurred in a defined contribution plan due to participant turnover if 
the turnover rate of participating employees is at least 20 percent. Both vested and nonvested employees are included in this calculation.  
The conclusion is based on the specific facts in the revenue ruling, involving closing a business location.
411(d)(3)

Line b. A qualified plan must provide that if it merges or consolidates with, or transfers assets or liabilities to, any other plan after Septem-
ber 2, 1974, each participant will (if the plan is terminated) receive a benefit immediately after the merger, etc., which is equal to or greater 
than the benefit the participant was entitled to immediately before the merger, etc., (if the plan had then terminated).
401(a)(12)

Lines c. and d. When an employer terminates an overfunded defined benefit plan, receives the excess assets, and then establishes a 
new defined benefit plan covering the active employees (“termination/reestablishment” transaction), the employer may not recover any 
surplus assets until it has fully vested all participants’ accrued benefits and has made lump sum distributions or purchased guaranteed 
annuity contracts to protect accrued benefits. In this regard, section 411(d)(6) and Rev. Rul. 85-6 require that plans provide for satisfaction 
of contingent liabilities to participants who have elected certain optional forms of benefit payment. If guaranteed annuity contracts or lump 
sum distributions have not been made by the terminated plans, favorable determination letters for the terminated and replacement plans 
will contain the appropriate selective caveat.
  
An employer that terminates an over-funded defined benefit plan may maintain a replacement defined benefit plan covering the same 
group of employees. The prior plan and the replacement plan, in combination, may provide benefits for each participant equivalent to 
those to which the participant would have been entitled if the prior plan had continued without interruption. The new plan may grant past 
service credit for the period during which an employee was covered by the terminated plan (subject to the limita¬tions of section 415). 
An employer may not recover surplus assets in a transaction in which it splits an over-funded defined benefit plan into two defined benefit 
plans, terminates one of the plans and receives the excess assets (“spinoff/termination” transaction), unless the following conditions are 
satisfied:

  (i) The benefits of all employees (including those employees covered by the ongoing plan) must be fully vested and nonforfeitable as 
  of the date of termination.

  (ii)  All benefits accrued as of the date of termination for all employees (including those employees covered by the ongoing plan) must 
  be provided for by the purchase of guaranteed annuity contracts.

If, in the original plan guaranteed annuity contracts have not been purchased for all covered employees, a favorable determination letter 
may not be issued unless the employer has given written assurance that guaranteed annuity contracts will be purchased or lump sums 
paid for employees, (see note below). Further, any such favorable determination letter on the ongoing and terminated plan must contain 
the appropriate selective caveat. The caveat is found in IRM Chapter 7.13.5 (see letter exhibits).

Note that the lump sum payments may not be made or annuity contracts distributed to the active participants under the ongoing plan 
unless such participants have attained normal retirement age. See also section 411(a)(11) requiring consent for certain “cash-outs”.
In general, these requirements apply to termination/reestablishment and spinoff/termination cases where the termination and the reestab         -
lishment or the spinoff and termination occur within a five year period.
Implementation Guidelines, Treasury news release dated May 24, 1984
401(a) (2)
Rev. Rul. 85-6, 1985-1 C.B. 133

Line e. One of the requirements for plan qualification is that the plan be intended to be permanent. A plan may not satisfy the perma           -
nency test of the income tax regulations if, within 15 years of the termination of a defined benefit plan involving a reversion of assets, an 
employer has previously received a reversion of assets upon termination of a defined benefit plan which covered some or all of the same 
employees.
Implementation Guidelines, Treasury news release dated  May 24, 1984
IRM  7.12.1.2.10 – Employee Plans Guidelines – Plan Terminations

Il. Benefits

Line a. A qualified pension, profit-sharing, or stock bonus plan may not permit the assignment or pledging of nonforfeitable plan benefits 
as security for loans. Under section 401(a)(13), a trust forming part of a stock bonus, pension, or profit-sharing plan will not be qualified 
unless the plan which the trust is a part of provides that the plan’s benefits may not be assigned or alienated. There are, however, excep      -
tions to this general rule:

  (1) A plan may provide that, after a benefit is in pay status, the participant receiving the benefit may make a voluntary and revocable 

Page 3                                                                 CYCLE A Submission Period – 02/01/2016 – 01/31/2017
assignment (not more than 10 percent of any benefit payment), if the assignment is not to defray plan administrative costs.

(2) A loan, made to a participant or beneficiary and secured by the participant’s nonforfeitable benefit, will not be treated as an assign -
ment or alienation if the loan is exempt from the excise tax on prohibited transactions imposed by Code section 4975. This exception 
applies only to loans from the plan and not to loans from third parties. A plan will not meet the requirements of section 401(a)(13) if it 
permits the assignment or pledging of nonforfeitable benefits as security for loans from a party other than the plan.

(3) If a “qualified domestic relations order” requires the distribution of all or part of a participant’s benefits under a plan to an alternative 
payee, the payment of such benefits will not be treated as an assignment or alienation of benefits prohibited by section 401(a)(13). A 
“qualified domestic relations order” is a “domestic relations order,” within the meaning of Code section 414(p)(1)(B), which (i) creates 
or recognizes the existence of an alternative payee’s right to, or assigns to an alternate payee the right to receive all or a portion of the 
benefits payable to a participant under a plan; (ii) specifies the information required by section 414(p)(2); (iii) does not require a plan 
to provide any type or form of benefit, or any option, not otherwise provided under the plan; (iv) does not require the plan to provide 
increased benefits (determined on the basis of actuarial value); and (v) does not require the payment of benefits to an alternate payee 
that are required to be paid to another alternate payee under another order previously determined to be a qualified domestic relations 
order. An “alternate payee” is a spouse, former spouse, child or other dependent of a participant who is recognized by a domestic rela-
tions order as having a right to receive all, or a portion of, the benefits payable under a plan with respect to such participant.

(4) A participant’s benefits under a plan may be offset to satisfy the participant’s liability to a plan due to the participant’s conviction of a 
crime, certain civil judgments, and certain settlement agreements involving the participant and the Department of Labor or the Pension 
Benefit Guaranty Corporation. In certain circumstances the spouse must consent to this offset. See section 401(a)(13)(C).
401(a)(13)
414(p)

Line b. A qualified plan must provide that, unless a participant elects otherwise, payments of benefits will begin not later than the 60th day 
after the close of the plan year in which the latest of these events occur: (1) the participant reaches either the plan’s normal retirement 
age or 65, whichever comes first; (2) the 10th anniversary of the year in which the participant started participation in the plan or, (3) the 
participant terminates service with the employer.

Although a plan is not required to provide an election for further deferrals, it may permit a participant to ask that payment of any benefit 
begin at a date later than the dates described above. Then, the plan must require the participant to make an election by submitting to 
the plan administrator a written statement which describes the benefit and states the date on which payment is to begin. Distribution of a 
participant’s benefit must, of course, comply with the requirements of section 401(a)(9). See Worksheet No. 9.
401(a)(14)
1.401(a)-(14)

Line c. A pension plan may not provide benefits before a participant reaches age 62 or, if earlier, reaches normal retirement age, termi   -
nates service, dies, or becomes disabled; profit-sharing and stock bonus plans may provide for payment before the normal retirement 
age or termination of service.

‘Applicable plans’ within the meaning of Code section 411(f) , as added by Division P of the Consolidated and Further Continuing Appro-
priations Act of 2015, can provide for a retirement age which would not otherwise meet minimum age requirements supplied by other 
provisions of ERISA and the Code and regulations thereunder. For purposes of this subsection, an applicable plan is a defined benefit 
plan the terms of which, on or before December 8, 2014, provided for a normal retirement age which is the earlier of (i) an age otherwise 
permitted under ERISA section 3(24), or (ii) the age at which a participant completes the number of years (not less than 30 years) of 
benefit accrual service specified by the plan.

A plan shall not fail to be treated as an applicable plan solely because the normal retirement age described in the preceding sentence 
only applied to certain participants or only applied to employees of certain employers.  A defined benefit plan shall be an applicable plan 
only with respect to an individual who (i) is a participant in the plan on or before January 1, 2017, or (ii) is an employee at any time on or 
before January 1, 2017, of any employer maintaining the plan, and who becomes a participant in such plan after such date.
401(a)(36); 411(f); 1.401-1(b)(1)(i) & (ii)

Line d. To be qualified, a plan (defined benefit and defined contribution) that provides for payment of any early retirement benefit when 
a stated period of service is completed and a stated age is reached must also provide that a participant who has met the service require-
ment (and is vested in it) will receive the benefit when the age requirement is satisfied. The benefit may be actuarially reduced, however, 
it may not be less than the reduced normal retirement benefit (the benefit to which the participant would have been entitled under the plan 
at normal retirement age, reduced by reasonable actuarial assumptions).
401(a)(14)
1.401(a)-14(c)

Line e. A qualified plan must give the distributee of an eligible rollover distribution the option of having the distribution paid in a direct 
rollover to an eligible retirement plan specified by the distributee. For this purpose, a distributee includes only the employee and the em-
ployee’s surviving spouse (or the employee’s spouse or former spouse, if designated as an alternate payee under a qualified domestic 
relations order).

Page 4                                                                  CYCLE A Submission Period – 02/01/2016 – 01/31/2017
An eligible rollover distribution is generally any distribution of all or any portion of the balance to the credit of the employee in the plan. 
However, an eligible rollover distribution does not include any distribution required by section 401(a)(9), or any distribution that is one 
of a series of substantially equal periodic payments over at least ten years or over the life or life expectancy of the employee or of the 
employee and a designated beneficiary, and hardship distributions. Certain other distributions, such as corrective distributions of excess 
contributions or excess deferrals under a qualified CODA, are not eligible rollover distributions. Hardship distributions are excluded from 
eligible rollover distributions.

An eligible retirement plan is an IRA, a plan qualified under IRC section 401(a) or 403(a), a 403(b) plan, or a 457(b) plan, that accepts the 
distributee’s eligible rollover distribution. 

A direct rollover means that the distribution is paid directly to the eligible retirement plan. This may be accomplished by any reasonable 
means of direct payment.

An eligible rollover distribution also may include after-tax employee contributions which are not includible in gross income.  However, for 
tax years beginning before January 1, 2007, such portion may only be transferred to an IRA or to a qualified plan under section 401(a) or 
403(a) that agrees to separately account for the transferred amounts including separately accounting for the portion of such distribution 
which is includible in gross income and the portion of such distribution which is not so includible.  For tax years beginning after December 
31, 2006, nontaxable distributions from a qualified plan can be directly rolled over to another qualified plan, an IRA, or a 403(b) plan if the 
separate accounting requirements for the amounts transferred (and the earnings thereon) are met.  

An eligible rollover distribution from a designated Roth account can only go to a Roth IRA or another designated Roth account.  Plans that 
include a qualified Roth contribution program may allow an eligible rollover distribution made after September 27, 2010, to be rolled over 
from accounts other than designated Roth accounts to designated Roth accounts under the plan.

The plan administrator may prescribe any reasonable procedures for the distributee to elect a direct rollover. In addition, the plan may 
provide that a distributee will not be allowed to elect a direct rollover if the distributee’s eligible rollover distributions for the year are rea-
sonably expected to total less than $200.
401(a)(31)
402(c)(2)(A), 402(c)(4)(A)
402(c)(8)(B)
1 401(a) (31)-1
1.402(c)-2
Notice 2001-57
Notice 2002-3
Notice 2010-84

Line f and g. Automatic rollover requirements apply to certain mandatory distributions under a plan. Pursuant to section 411(a)(11), if the 
present value of any nonforfeitable accrued benefit exceeds $5,000, a plan must provide that such benefit is not immediately distributable 
without the consent of the participant. Therefore, a plan may provide that amounts that do not exceed $5,000 may be immediately distrib-
utable without consent.  Under section 401(a)(31)(B), when a distributee of any mandatory distribution that is an eligible rollover distribu-
tion does not elect to have the distribution transferred to an eligible retirement plan or to receive it directly, and the distribution exceeds 
$1,000, then the plan administrator must transfer the amount to an individual retirement plan and give the participant written notice.  This 
rule applies to mandatory distributions made on or after March 28, 2005.
401(a)(31)(B)
Notice 2005-5
Notice 2005-95

Line h. A qualified plan must provide that, in the case of a participant who dies while performing qualified military service, the survivors 
of the participant are entitled to any additional benefits (other than benefit accruals relating to the period of military service) that would 
have been provided under the plan had the participant resumed employment and then terminated employment on account of death. Ser-
vice credit for the period of the deceased participant’s period of qualified military service must also be provided. This provision applies to 
deaths occurring after December 31, 2006. A plan amendment must be made to reflect this change on or before the last day of the first 
plan year beginning on or after January 1, 2010.   
401(a)(37)
Notice 2010-15, 2010-1 I.R.B. 390

Line i. Effective for plan years beginning after December 31, 2009, a qualified plan must allow a nonspouse designated beneficiary to 
directly rollover any portion of a plan distribution to an inherited IRA of the nonspouse designated beneficiary.
402(c)(11)

Ill. General Qualification Issues

Line a. Under the trust instrument it must be impossible at any time before the satisfaction of all liabilities with respect to employees and 
their beneficiaries under the trust, for any part of the corpus or income to be (within the year or after it) used for, or diverted to, purposes 
other than for the exclusive benefit of such employees or their beneficiaries. The statute provides a limited exception for certain contri-
butions to multi-employer plans. In addition, Rev. Rul. 91-4 provides that the general prohibition against diversion does not preclude the 

Page 5                                               CYCLE A Submission Period – 02/01/2016 – 01/31/2017
return of a contribution an employer makes if (1) the contribution is made by reason of mistake of fact; (2) the contribution is conditioned 
on initial qualification of the plan, a determination letter application is filed by the due date of the return for the taxable year in which the 
plan was adopted or any prescribed later date (i.e., a later section 401(b) date), and the plan receives an adverse determination; or (3) the 
contribution is conditioned on its deductibility under section 404 The contribution’s return must be made within one year of the mistaken 
payment of the contribution, denial of qualification, or disallowance of the deduction, as the case may be. Nondeductible contributions 
to a qualified defined benefit plan of less than $25,000 may be treated as disallowed and thus may be returned to the employer if the 
plan specifically allows the return of contributions determined by the Service to be nondeductible and the contribution is conditioned on 
deductibility. 
401(a)(2)
1.401-2(b)(1)
Rev. Rul. 91-4, 199 1-1 C.B. 57
Rev. Rul. 90-49, 1990-2 C.B. 620

Line b. A plan shall not be qualified unless it provides that an employee’s right to his or her normal retirement benefit is nonforfeitable 
on attainment of normal retirement age as defined in Code section 411(a)(8), that is, the earlier of normal retirement age under the plan 
or the later of age 65 or the 5th anniversary of participation commencement. If a plan defines normal retirement date as the first day of 
the month coincident with or following the date on which a participant reaches age 65, and provides that a participant’s right to his or her 
normal retirement benefit is nonforfeitable at the normal retirement date a participant might not be fully vested at his or her normal retire-
ment age as required by section 411(a); 
411 (a)(8)
1.411 (a)-7(b) 

Line c. A profit sharing plan must have a predetermined formula for allocating employer contributions that precludes employer discretion. 
One such method is to allocate contributions in proportion to compensation. The allocation formula may also take into account years of 
service, but this may be discriminatory.
401(a)(4)
1.401-1 (b)(1)(ii)

Line d. A pension plan within the meaning of section 401(a) is a plan established and maintained by an employer primarily to provide 
systematically for the payment of definitely determinable benefits to his or her employees over a period of years, usually for life, after re-
tirement. A plan so designed will be considered a pension plan if employer contributions under the plan can be determined actuarially on 
the basis of definitely determinable benefits, or, in the case of a money purchase plan, such contributions are fixed without being geared 
to profits. This requirement will be satisfied if the employer-provided benefit under the plan can be determined under an express formula 
stated in the plan that does not involve employer discretion. For example, the definitely determinable benefit requirement will not be sat-
isfied unless the percentage of the survivor portion of the qualified joint and survivor annuity of a pension plan is not within the discretion 
of the plan sponsor.

Under a money purchase pension plan, however (but not under a defined benefit plan), forfeitures may be applied to increase the benefit 
any employee would otherwise receive under the plan. 
401(a)(8)
1.401-1(b)(1)(i)
Rev. Rul. 74-385, 1974-2 C.B. 130

Line e. Defined benefit plans that provide for the payment of optional benefit forms that are the actuarial equivalent of the normal re      -
tirement benefit payable under the plan, like any other pension plan, must provide for the payment of definitely determinable benefits 
as required by section 1.401-1(b)(1)(i) of the regulations. See Rev. Rul. 69-427 which deals with the application of this rule to a plan 
that provides disability bene¬fits and early retirement benefits. Whenever the amount of a benefit in a plan is to be determined by some 
procedure that requires the use of actuarial assumptions, (interest, mortality, etc.) the assumptions to be used must be specified within 
the plan in a manner which precludes employer discretion. Such assumptions may be fixed or variable as long as they do not involve 
employer discretion.
401(a)(25)
1.401-1 (b)(1)(i)
Rev. Rul. 69-427, 1969-2 C.B. 87
Rev. Rul. 79-90,1979-1 C.B. 155

Line f. Under Rev. Rul. 74-307, preretirement death benefits under a pension plan of any type will be considered incidental if either (1) 
less than 50 percent of the employer contribution credited to each participant’s account is used to purchase ordinary life insurance poli-
cies on the participant’s life even if the total death benefit consists of both the face amount of the policies and the amount credited to the 
participant’s account at the time of death, or (2) the total death benefit before normal retirement date does not exceed the greater of (a) 
the proceeds of ordinary life insurance policies providing a death benefit of 100 times the anticipated monthly normal retirement benefit, 
or (b) the sum of (i) the reserve under the ordinary life insurance policies plus (ii) the participant’s account in the auxiliary fund.

Rev. Rul. 74-307 is directly applicable to defined contribution pension plans (i.e., money purchase pension plans), but can not be directly 
applied to defined benefit plans. The reason for this is that there are no participants’ accounts in a defined benefit plan. Also, employer 
contributions are not allocable to individual participants’ accounts, but are made to fund the benefits of the plan as whole. However, the 
general prin¬ciple of Rev. Rul. 74-307, that death benefits will be consid¬ered incidental if less than a stated percentage of employer 

Page 6                                                             CYCLE A Submission Period – 02/01/2016 – 01/31/2017
contributions made on behalf of each participant are used to purchase life insurance, can apply to defined benefit plans.

To apply the “50 percent” rule of Rev. Rul. 74-307 to defined benefit plans, an amount representing the “employer contribution for a par      -
ticipant” must be computed. This amount is the “theoretical contribution” which is the contribution that would be made on behalf of the 
participant, using the individual level premium funding method from the age at which participation commenced to normal retirement age, 
to fund the participant’s entire retirement benefit without regard to preretirement ancillary benefits. The theoretical contribution is comput-
ed based upon reasonable actuarial assumptions (i.e., interest rate, mortality) that must be stated in the plan.

The “amount credited to the participant’s account at the time of death” for this purpose is the theoretical individual level premium reserve 
that is computed using the theoretical contribution. The theoretical individual level premium reserve is the reserve that would be available 
at time of death if for each year of plan participation a contribution had been made on behalf of the participant in an amount equal to the 
theoretical contribution.

In applying Rev. Rul. 74-307 to defined benefit plans the maximum premiums for ordinary life insurance may be no more than 66 (33 if 
term and/or universal life insurance) percent of the theoretical contribution. The death benefit payable may not exceed the face amount of 
the insurance policies plus the theoretical individual level premium reserve less the cash value of the insurance policies.

In addition to incidental death benefits under the above application of Rev. Rul. 74-307, preretirement death benefits under a defined 
benefit plan will also be considered incidental if: (1) the cost of the death benefit for any individual does not exceed 25 percent of the total 
cost of the individual’s benefit, (2) the death benefit is not greater than 100 times a participant’s anticipated monthly annuity, (3) the death 
benefit is equal to the present value of the participant’s accrued benefit, or (4) a surviving spouse’s annuity benefit is a stated percentage 
of the deceased participant’s accrued benefit or a stated percentage of the anticipated normal retirement benefit where the stated per        -
centage is within the guidelines set forth in Rev. Rul. 70-611, as modified by Rev. Rul. 85-15.

In the case of a defined contribution plan that provides for the use of trust funds to purchase and pay premiums on ordinary life insurance 
contracts, the death benefit, which can include the participant’s account balance, is deemed to be incidental if: (1) the aggregate life in   -
surance premiums that have been paid with funds which have not been accumulated for at least 2 years for each participant are less than 
one-half of the aggregate of the contributions allocated to the credit of the participant at any particular time, and (2) the plan requires the 
trustee to convert the entire value of the life insurance contract at or before retirement into cash, or to provide periodic income so that no 
portion of such value may be used to continue life insurance protection beyond retirement, or to distribute the contract to the participant.
The same general 25 percent incidental benefit rule that applies for defined benefit plans also applies for defined contribution plans. Any 
lump sum death benefit provided by life insurance contracts under a defined contribution plan is deemed to be incidental if the premiums 
on the contracts purchased on behalf of a participant do not exceed 25 percent of the employer contributions allocated to the participant’s 
account. Further, if the plan meets the rules ordinarily applicable to defined benefit plans, it will meet the incidental death benefit rule.

The rules discussed above relate to whether death benefits under defined benefit or defined contribution plans are incidental within the 
meaning of section 1.401-1(b)(1) of the regulations. Section 401(a)(11) of the Code, however, requires certain plans to provide automatic 
survivor benefits to the surviving spouse of a vested participant who dies before retirement. With an exception for plans described in 
section 401(a)(11)(C), a “qualified preretirement survivor annuity,” as defined in section 417(c), is required to be provided by any defined 
benefit plan or any money purchase pension plan. A profit-sharing or stock bonus plan must also provide the qualified preretirement sur-
vivor annuity unless the plan satisfies certain requirements in section 401(a)(11)(B)(iii).

As explained in Rev. Rul. 85-15, the qualified preretirement survivor annuity is a preretirement death benefit that must be taken into ac     -
count in determining whether death benefits under a plan are incidental within the meaning of section 1.401-1 (b)(1) of the regulations. A 
plan under which the only preretirement death benefit is a qualified preretirement survivor annuity will satisfy the incidental death benefit 
requirement of section 1.401-1 (b)(1) of the regulations.

If a plan provides any preretirement death benefit (i.e., a lump sum death benefit) in addition to the qualified preretirement survivor annui -
ty, such benefits considered together will be deemed incidental so long as the value of the qualified preretirement survivor annuity and the 
additional death benefit do not exceed the maximum death benefit allowable under one of the rules discussed above relating to incidental 
death benefits under a defined benefit plan or defined contribution plan, whichever the case may be. In order to satisfy the incidental death 
benefit rule, a plan may be required to offset the value of the qualified preretirement survivor annuity against the additional death benefit, 
and only the excess, if any, of the additional benefit over the value of the qualified preretirement survivor annuity would be provided along 
with the qualified preretirement survivor annuity.

If under a pension plan, lump sum death benefits are to be offset by the value of the qualified preretirement survivor annuity to satisfy 
the incidental death benefit requirement of section 1.401-1(b)(1) of the regulations, the plan must specify the actuarial assumptions 
necessary, including the assumptions for determining the lump sum value of the survivor annuity, in order to make the benefits definitely 
determinable as required by section 401(a)(25) and Rev. Rul. 79-90.

Besides the preretirement incidental requirement described in the preceding paragraphs, a plan must also satisfy the minimum distribu-
tion incidental benefit (MDIB) requirement. See Worksheet No. 9 regarding the MDIB requirement. 
401(a)(11)
401(a)(25)
1.401-1(b)(1)(i) & (ii)
Rev. Rul. 60-83, 1960-1 C.B 157

Page 7                                                        CYCLE A Submission Period – 02/01/2016 – 01/31/2017
Rev. Rul. 60-84, 1960-1 C.B. 159
Rev. Rul. 66-143, 1966-1 C.B. 79
Rev. Rul. 68-3 1, 1968-1 C.B. 151
Rev. Rul. 70-6 11, 1970-2 C.B. 89
Rev. Rul. 74-307, 1974-2 C.B. 126
Rev. Rul. 79-90, 19 79-1 C.B. 155
Rev. Rul. 85-15, 1985-1 C.B. 132

Line g. A pension or annuity plan may provide for the payment of sickness, accident, hospitalization, and medical expenses of retired 
employees and their spouses and dependents provided certain conditions are met.

First, a separate account (a “section 401(h) account”) must be established and maintained for the retiree medical benefits under the plan. 
(For any key employee, a separate account must also be maintained for the benefits payable to that employee (or spouse or depen            -
dents) and, generally, medical benefits payable to that employee (or spouse or dependents) may come only from that separate account.) 
Second, the employer’s contributions to the 401(h) account must be reasonable and ascertainable. Third, it must be impossible for the 
corpus or income of the 401(h) account to be used for or diverted to a purpose other than providing the retiree medical benefits prior to the 
satisfaction of all liabilities under the plan to provide such benefits. Fourth, the terms of the plan must provide that, upon the satisfaction 
of all liabilities under the plan to provide the retiree medical benefits, all amounts remaining in the 401(h) account must be returned to the 
employer.

Finally, the retiree medical benefits must be subordinate to the retirement benefits provided by the plan. This requirement will not be sat-
isfied unless the plan provides that the aggregate actual contributions for retiree medical benefits, when added to the actual contributions 
for life insurance under the plan, are limited to 25 percent of the total actual contributions made to the plan (other than contributions to 
fund past service credits) after the later of the adoption or effective date of the section 401(h) arrangement.
401(h)

Line h. If a plan permits the transfer of assets in a defined benefit plan to a section 401(h) health benefit account, see section 16 and 
appendix of Rev. Proc. 2007-6, 2007-1 I.R.B.189

Line i. All defined contribution plans must provide for a valu¬ation of investments held by the trust at least once a year, on a specified 
inventory date, in accordance with a method consistently followed and uniformly applied. The fair market value on the inventory date is to 
be used for this purpose, and the respective accounts of participants are to be adjusted in accordance with the valuation.
Rev. Rul. 80-155, 1980-1 C.B. 84

Line j. Certain corrective amendments that are made after the end of a plan year may be taken into account in determining whether a 
plan satisfies the minimum coverage or nondiscrimination requirements for such year. That is, the amendment may be treated as if it were 
adopted and effective as of the first day of the plan year even though it is in fact adopted after the end of the year. This rule applies in 
addition to the remedial amendment provisions described above.

If a corrective amendment to satisfy the minimum coverage or nondiscrimination requirements (other than an amendment permitted under 
the remedial amendment rules of section 401(b)) is being taken into account prior to its adoption, this line should be completed.

To satisfy the minimum coverage, nondiscrimination in amount, or nondiscriminatory plan amendment requirements (see Worksheet 5), 
a corrective amendment may retroactively increase accruals or allocations for employees who benefitted under the plan during the plan 
year being corrected or may provide accruals or allocations to employees who did not benefit during the plan year being corrected. To 
satisfy the nondiscriminatory current availability requirement that applies to benefits, rights, and features (see Worksheet 5), a corrective 
amendment may expand the availability of the benefit, right, or feature to employees to whom it was not previously available.

A corrective amendment may be taken into account prior to its adoption only if the following conditions are satisfied:

1. The amendment may not reduce any employee’s benefits determined under the plan prior to the amendment.  The amendment must 
generally be effective as if it had been adopted on the first day of the year being corrected that is, it must be treated as if in effect for 
the entire year. (An amendment to extend the availability of a benefit, right, or feature does not fail this requirement merely because it 
is not made effective prior to its adoption date.)

2. The amendment must be adopted and implemented on or before the 15th day of the 10th month after the close of the plan year being 
corrected. (This deadline is automatically extended by the filing of a determination letter request before the deadline. The extension is 
until the expiration of 91 days after disposition (e.g., issuance of a letter) of the request.)

3. The amendment must be adopted and implemented on or before the 15th day of the 10th month after the close of the plan year being 
corrected. (This deadline is automatically extended by the filing of a determination letter request before the deadline. The extension is 
until the expiration of 91 days after disposition (e.g., issuance of a letter) or the request.)

4. The additional allocations or accruals for the plan year being corrected that result from the amendment must separately satisfy 
section 401(a)(4) for that year and must benefit a group of employees that separately satisfies section 410(b). (This requirement does 
not apply if the purpose of the amendment is to conform the plan to a nondiscrimination in amount safe harbor.) The employer may be 

Page 8                                                                CYCLE A Submission Period – 02/01/2016 – 01/31/2017
asked to demonstrate that this requirement is satisfied.

Other conditions apply in the case of corrective amendments relating to the availability of benefits, rights, and features. Special rules also 
apply in the case of section 401(k) and section 401(m) plans. The specialist should refer to the regulations in these circumstances. The 
employer may be asked to demonstrate that these conditions and special rules are satisfied.

A nonsubstantive amendment may not be taken into account for purposes of the minimum coverage and nondiscrimination requirements.

For example, an amendment will not be taken into account to the extent it affects nonvested, terminated employees who would not have 
received any economic benefit from the amendment had it been adopted in the year being corrected.
1.401(a)(4)-11(g)

Line k. For plan years beginning after December 31, 2002, section 408(q) provides that a defined contribution plan may allow employees 
to make voluntary employee contributions to a separate account or annuity established under the plan which, if that account or annuity 
meets the applicable requirements of section 408 (traditional IRA) or section 408A (Roth IRA), will be treated as an individual retirement 
plan (i.e. a “deemed IRA”). In general, the defined contribution plan and the “deemed IRA” are treated as separate entities with each entity 
subject to the rules generally applicable to it.

A plan with a deemed individual retirement annuity must satisfy the requirements of section 408(b). Similarly, a plan with a deemed indi-
vidual retirement account must satisfy the requirements of section 408(a) except for the prohibition in section 408(a)(5) which is expressly 
excepted under 408(q). Accordingly, the assets of a deemed IRA may be commingled for investment purposes with the other assets of 
the plan. However, the plan must still restrict the commingling of deemed IRA assets with non-plan assets.

Deemed individual retirement accounts may be held in separate individual trusts, a single trust separate from a trust maintained by the 
defined contribution plan, or in a single trust that includes the defined contribution plan. If deemed IRAs are held in a single trust that 
includes the defined contribution plan, the plan must provide that the trustee shall maintain a separate account for each deemed IRA.

Deemed individual retirement annuities may be held under a single annuity contract or under separate annuity contracts. Where a single 
annuity contract is used, separate accounting for the interest of each participant is required. Also, the contract must be separate from any 
annuity contract of the plan.

As noted in Rev. Proc. 2003-13, plan language should address every applicable point in the IRA List of Required Modifications (LRMs) 
published on the Service’s web site at www.irs.gov/ep. Rev. Proc. 2003-13 also contains sample plan language to be used in conjunction 
with the IRA language. However, #5 of the sample plan amendment providing for separate trusts for deemed IRAs is no longer required. 
Section 1.408(q)-1(f) of the income tax regulations relating to deemed IRAs provides that a separate trust is not required in those cases 
in which the qualified employer plan maintains a trust, but only if separate accounting is maintained for each deemed IRA.
408(q)
408A
1.408(q)-1 and Rev. Proc. 2003-13

Line l. Section 401(a)(35)(A) provides that a trust which is part of an applicable defined contribution plan is not a qualified trust under 
section 401(a) unless the plan satisfies the diversification requirements of sections 401(a)(35)(B), (C), and (D).  

An applicable defined contribution plan under section 401(a)(35) is a defined contribution plan that holds any publicly traded employer 
securities.  A publicly traded employer security is an employer security under section 407(d)(1) of ERISA which is readily tradable on an 
established securities market; see section 1.401(a)(35)-1(f)(5) for additional rules.  See section 401(a)(35)(F) for a discussion of certain 
plans that are treated as holding publicly traded employer securities.

An ESOP is not an applicable defined contribution plan if the ESOP is a separate plan for purposes of section 414(l) and holds no contri-
butions (or earnings thereunder) that are, or were, subject to sections 401(k) or 401(m).   Such an ESOP remains subject to the diversifi -
cation requirements of section 401(a)(28)(B).    See Part V for amendments for ESOPs that are not applicable defined contribution plans.
With respect to the portion of the account that is subject to sections 401(a)(35)(B) and (C), an applicable individual (a person entitled to 
receive diversification rights) is required to be permitted to elect to direct the plan to divest any publicly traded employer securities held in 
his or her account under the plan and to reinvest an equivalent amount in other investment options offered under the plan.  

The diversification rights under section 401(a)(35)(B) apply to elective deferrals and employee contributions and are required to be avail-
able to (1) any participant, (2) any alternate payee who has an account balance under the plan, and (3) any beneficiary of a deceased 
participant.  For this purpose, employee contributions include both employee after-tax contributions and rollover contributions held under 
the plan.  

The diversification rights under section 401(a)(35)(C) apply to other employer contributions and are required to be available to each 
applicable individual who is either (1) a participant who has completed at least three years of service, (2) an alternate payee who has an 
account under the plan with respect to a participant who has completed at least three years of service, or (3) a beneficiary of a deceased 
participant. See section 1.401(a)(35)-1(c)(3) for rules concerning the completion of three years of service.

Under section 401(a)(35)(D) and section 1.401(a)(35)-1(d), the investment options offered must include not less than three investment 

Page 9                                            CYCLE A Submission Period – 02/01/2016 – 01/31/2017
options, other than employer securities, to which the applicable individual may direct the proceeds of the divestment of employer securi-
ties, and each investment option must be diversified and have materially different risk and return characteristics.  A plan may limit the time 
for divestment and reinvestment to periodic, reasonable opportunities occurring no less frequently than quarterly. 

Section 401(a)(35)(D)(ii)(II) prohibits a plan from imposing restrictions or conditions with respect to the investment of employer securi-
ties which are not imposed on the investment of other assets of the plan, with an exception for any restrictions or conditions imposed to 
comply with securities laws.  See section 1.401(a)(35)-1(e)(1) for rules concerning impermissible restrictions or conditions; see section 
1.401(a)(35)-1(e)(1)(ii) for rules concerning indirect restrictions or conditions; and see 1.401(a)(35)-1(e)(2) for rules concerning permitted 
restrictions or conditions.

An ESOP that was subject to section 401(a)(28)(B) and provided for in-service distributions in accordance with section 401(a)(28)(B)(ii)
(I), but is now subject to section 401(a)(35) may be amended to eliminate such distributions without violating section 411(d)(6).
The diversification requirements of section 401(a)(35) are generally effective with respect to plan years beginning after December 31, 
2006, subject to certain special effective date rules, including a special rule with respect to plans maintained pursuant to a collective bar-
gaining agreement. See section 901(c) of PPA ’06. 

Notice 2006-107, 2006-2 C.B. 1114, includes guidance and transitional rules with respect to the diversification requirements of section 
401(a)(35).  The transition guidance was extended in Notice 2008-7 until the regulations under section 401(a)(35) become effective.  
Proposed regulations were published January 3, 2008 (73 Fed. Reg. 421) and were effective for plan years beginning on or after January 
1, 2009.

Notice 2009-97, 2009-52 I.R.B. 972, extends the deadline to amend for section 401(a)(35) to the last day of the first plan year that begins 
on or after January 1, 2010.

Final regulations were published May 19, 2010 (75 Fed. Reg. 27927), and are effective and applicable for plan years beginning on or 
after January 1, 2011.
Notice 2006-107, 2006-2 C.B. 1114, as modified by Notice 2008-7, 2008-1 C.B. 276
Notice 2009-97, 2009-52 I.R.B. 972
Notice 2013-17, 2013-20 I.R.B. 1082
401(a)(35)
1.401(a)(35)-1

Line m. If a defined contribution plan (other than a profit-sharing plan) is established by an employer whose stock is not readily tradable 
on an established securities market within the meaning of section 1.401(a)(35)-1(f)(5), and if after acquiring securities of the employer, 
more than 10 percent of the total assets of the plan are securities of the employer, the plan is subject to Code section 409(e).  See Line 
h in Part V.
401(a)(22)
409(e)
1.401(a)(35)-1(f)(5)
Notice 2011-19

Line n. If the plan is a stock bonus plan, it is subject to Code sections 409(h) and (o).  See Lines I and j in Part V.  Note that, for purposes 
of Code section 409(h), the term “employer securities” includes any securities of the employer held by the plan.
401(a)(23) 

IV. Compensation Limit

Line a. Section 401(a)(17) requires that a qualified plan must provide that the compensation taken into account for any employee in de-
termining contributions or benefits for a plan year is limited to the annual compensation limit. The annual compensation limit for plan years 
beginning after December 31, 2001 is $200,000.
1.401(a) (17)-1(b)

The following applies to plan years beginning before January 1, 2002. For plan years beginning after December 31, 2001, see below:

The annual compensation limit for plan years beginning before January 1, 1994, is $200,000, adjusted, beginning on January 1, 1990, 
in the same manner as under section 415(d). The annual compensation limit for plan years beginning on or after January 1, 1994, is 
$150,000, adjusted, for changes in the cost of living as under section 415(d). However, the $150,000 amount will be adjusted only when 
the adjustment yields an increase in the annual compensation limit of at least $10,000, and adjustments will be made only in increments 
of $10,000. Adjustments in the annual compensation limit may not be taken into account prior to the plan year beginning in the calendar 
year for which the adjustment takes effect. For years beginning after December 31, 1994, the base period is the calendar quarter begin-
ning October 1, 1993.

If compensation for a prior year is used in determining contributions or benefits for the plan year, the applicable compensation limit is the 
limit in effect for the prior year.

The annual compensation limit under section 401(a)(17) first applies in the first 1989 plan year. Thus, allocations or benefits accrued for 

Page 10                                                                       CYCLE A Submission Period – 02/01/2016 – 01/31/2017
plan years beginning before 1989 (the “statutory effective date”) are not subject to the annual compensation limit. Also, allocations or ben-
efits accrued for plan years beginning on or after the statutory effective date but before the 1994 plan year are not subject to the $150,000 
limit. However, if an employer generally amends a plan to increase prior benefits for years before either the statutory or OBRA ’93 effective 
date, the employer may not treat these benefits as accrued in the prior years (thereby avoiding either the $200,000 or the $150,000 limit).
Allocations for plan years beginning before the statutory effective date, even if based on compensation in excess of $200,000, do not 
limit allocations in later years. However, if compensation for a year beginning prior to the statutory effective date is used in determining 
contributions or benefits for the 1989 plan year or a later plan year beginning before January 1, 1994, then the compensation limit for that 
prior year is $200,000. Similarly, allocations for plan years beginning before January 1, 1994 (the “OBRA ’93 effective date”), even if based 
on compensation in excess of $150,000, do not limit allocations in later years. However, if compensation for a year beginning prior to the 
OBRA ’93 effective date is used in determining contributions or benefits for the 1994 plan year or a later plan year, then the compensation 
limit for that prior year is $150,000.
1.401(a) (17)-1 (a) & (b)

For purposes of section 401(a)(17), a plan may determine the compensation that is used in computing contributions for the plan year on 
the basis of compensation for that plan year. A plan may also determine compensation on the basis of a 12 consecutive month period, or 
periods, ending within the plan year. In this case, the applicable limit that applies to compensation for such periods is the limit in effect for 
the calendar year in which each 12 month period begins.
1.401(a)(17)-1(b)(3)(ii)

If the plan determines compensation on a period of time less than 12 months, or in the case of a plan year of less than 12 months, then the 
otherwise applicable limit is proportion¬ately reduced for the number of months fewer than 12. Proration is not required merely because 
accruals or allocations are based on compensation for that portion of the plan year during which the employee is a participant. Proration is 
also not required for employees covered under the plan for less than a full plan year provided their allocations are based on compensation 
for a period of at least twelve months.
1.401(a)(17)-1(b)(3)(iii)

In the case of a plan maintained by more than one employer, the annual compensation limit applies separately with respect to the com-
pensation of an employee from each employer maintaining the plan.
1.401(a)(17)-1(b)(4)

For years beginning before January 1, 1997, the family aggregation rules of section 414(q), as modified by section 401(a)(17) apply with 
respect to the requirement that the plan must limit the amount of contributions taken into account in determining contributions. That is, 
the plan must treat the following family unit as a single employee with one compensation to which the annual compensation limit under 
the plan applies: an employee who is either a 5% owner or is both a highly compensated employee and one of the ten most highly com-
pensated employees, such employee’s spouse, and any lineal descendants of such employee who have not attained age 19 before the 
close of the year. If the compensation for the family unit exceeds the annual compensation limit, then the plan must specify how the limit 
will be allocated among the members of the family unit. However, if the plan provides for permitted disparity under section 401(i), this 
proration is not to be applied for purposes of determining the portion of each individual’s compensation that is below the integration level.
These aggregation rules have been repealed effective for years beginning after December 31, 1996. If compensation for any year begin-
ning before January 1, 1997 is used in determining allocations or benefits (or in testing for nondiscrimina¬tion) in a plan year beginning 
after December 31, 1996, the compensation limit under section 401(a)(17) for that prior year is also determined without regard to family 
aggregation. Thus, for example, in applying the compensation limit for 1997 in a defined benefit plan that bases its benefit on the highest 
3 year average compensation, the family aggregation rules will be disregarded in determining the compensation limit for 1995 and 1996.
401(a)(17)
414(q)(6)(C)

For any plan year beginning after December 31, 2001, the annual compensation of each participant taken into account in determining allo-
cations shall not exceed $200,000, as adjusted for cost-of-living increases in accordance with section 401(a)(17)(B) of the Code. Section 
401(a)(17)(B) provides that the $200,000 amount shall be adjusted annually for increases in the cost of living at the same time and same 
manner as adjustments under section 415(d), except that the base period shall be the calendar quarter beginning July 1, 2001, and any 
increase which is not a multiple of $5,000 shall be rounded to the next lowest multiple of $5,000. The Commissioner generally publishes 
cost-of-living adjustments under section 401(a)(17)(B) and other sections in October of each year, applicable in the following year. 

Annual compensation means compensation during the plan year or such other consecutive 12-month period over which compensation is 
otherwise determined under the plan. The cost-of-living adjustment in effect for a calendar year applies to annual compensation for the 
determination period that begins with or within such calendar year.

Line b. A defined benefit plan must determine the accrued benefit of each section 401(a)(17) employee by applying the fresh-start rules 
described in section 1.401(a)(4)-13(c) (and, if applicable 1.401(a)(4)-13(d)) of the regulations and Worksheet #5A. Refer to Worksheet 
#5 and the accompanying explanation for a general discussion of the fresh-start rules under section 1.401(a)(4)-13(c) and (d) of the 
regulations.

Generally, an employee with an accrued benefit as of the last day of the 1988 plan year determined under a formula that took into account 
the employee’s compensation in excess of $200.000 is a section 401(a)(17) employee. (This benefit, frozen as of the last day of the 1988 
plan year, is referred to as the “section 401(a)(17) frozen accrued benefit.”)

Page 11                                                                         CYCLE A Submission Period – 02/01/2016 – 01/31/2017
Likewise, an employee with an accrued benefit as of the last day of the 1993 plan year determined under a formula that took into account 
the employee’s compensation in excess of $150,000 is generally a section 401(a)(17) employee. (This benefit, frozen as of the last day 
of the 1993 plan year, is referred to as the “OBRA ’93 frozen accrued benefit.”)

However, in either case, if the plan makes a fresh start using the formula with wear-away described in Worksheet 5 and the benefit 
determined by applying the current formula to total service (taking into account the annual compensation limit) exceeds the frozen (or 
adjusted) accrued benefit, the employee will not be a section 401(a)(17) employee. If it is determined that there are no section 401(a)(17) 
employees in the plan, answer this line on the worksheet “N/A”.

The fresh-start date that must be used for transitioning into compliance with section 401(a)(17) (the “section 401(a)(17) fresh-start date”) 
must be a date that is not earlier than the last day of the 1988 plan year and, generally, not later than the last day of the 1993 plan year. 
For this purpose, the fresh-start rules must be applied using a benefit formula, after amendment to comply with the section 401(a)(17) 
$200,000 annual compensation limit and the final regulations, as the formula applicable to accruals in the post-fresh-start year. In addition 
the plan must apply the fresh-start rules to transition into compliance with the OBRA ’93 $150,000 annual compen¬sation limit by using, 
generally, the last day of the 1993 plan year as the fresh-start date and using a benefit formula, after amendment to comply with the sec-
tion 401(a)(17) $150,000 annual compensation limit and the final regulations, as the formula applicable to accruals in the post-fresh-start 
year.

Generally, the plan may adjust either the section 401(a)(17) frozen accrued benefit or the OBRA ’93 frozen accrued benefit, or both, 
for post-fresh-start date compensation increases, as described in section 1.401(a)(4)-13(d) of the regulations and Worksheet 5A. If the 
plan is amended to make a fresh-start for all employees, it may provide that there will be no adjustment to the pre-fresh-start date frozen 
accrued benefit, adjustment will be made to the frozen accrued benefits of non-section 401(a)(17) employees only, or adjustment will be 
made to the frozen accrued benefits of all employees in the plan.

If the plan is adjusting section 401(a)(17) employees’ accrued benefits, the adjustment is made in one of two ways. The frozen accrued 
benefit may be adjusted by multiplying it by the “old compensation fraction” as defined in section 1.401(a)(4)-13(d)(8)(i) of the regula -
tions. In this case, the denominator is the employee’s compensation as of the fresh-start date, using the plan’s compensation formula 
(including the underlying definition and averaging period) as of that date and, in the case of an OBRA ’93 fresh-start date, reflecting the 
annual compensation limit that applied as of the fresh-start date. The numerator is the employee’s updated compensation, determined 
after applying the annual compensation limits to each year’s compensation used in the plan’s compensation formula. Alternatively, the 
plan may determine the employee’s adjusted accrued benefit by “plugging in” the employee’s updated compensation, determined after 
applying the annual compensation limits, in the formula used to determine the frozen accrued benefit. Thus, in either case there can be 
no adjustment until the updated compensation, determined after applying the annual compensation limit, exceeds the compensation used 
to determine the frozen accrued benefit.

If the plan makes multiple fresh starts with respect to an employee, and the frozen accrued benefit consists of a sum of a frozen accrued 
benefit (or adjusted accrued benefit) as of a previous fresh-start date plus additional frozen accruals since the previous fresh-start date, 
the adjustment described above must be made separately to the previously frozen accrued benefit and the additional frozen accruals to 
the extent that these have been determined using different compensation formulas or compensation limits. For example, this could occur 
where an employee’s frozen accrued benefit as of the OBRA ’93 fresh-start date consists of the section 401(a)(17) frozen accrued benefit 
plus accruals between the statutory effective date and the OBRA ’93 effective date. In this case, the denominators in the adjustment frac-
tions used to adjust the section 401(a)(17) frozen accrued benefit and the frozen accruals for years between the statutory effective date 
and the OBRA ’93 effective date will be different. In the former case, the denominator will not reflect any compensation limitation, while in 
the latter case the denominator will reflect the annual compensation limit as in effect under section 401(a)(17) in the years between the 
statutory effective date and the OBRA ’93 effective date.

A plan may be amended after either the section 401(a)(17) fresh-start date or the OBRA ’93 fresh-start date to provide a new optional 
form of benefit or to make an optional form of benefit available with respect to the applicable frozen accrued benefit, provided the optional 
form of benefit is not subsidized. If the plan adds an optional form of benefit with respect to an applicable frozen accrued benefit that is 
subsidized, the plan fails to satisfy section 401(a)(17).
1.401(a)(4)-13(c)
1.401(a)(4)-13(d)
1.401(a) (17)-1(e)

V. Amendments Relating to ESOPs

Line a. Regulation  54.4975-11(a)(2) requires that in order to be an ESOP, the plan document must have language that specifically desig  -
nates itself as an ESOP. The entire plan may be designated as an ESOP. However, Regulation §54.4975-11(a)(5) allows a plan to provide 
that only a portion of a qualified plan is an ESOP. For example, an ESOP could be a portion of a Profit Sharing Plan, or, an ESOP could 
be a portion of a Money Purchase Plan.

Section 4975(e)(7)(A) of the Code requires that an ESOP must also state that it is designed to invest primarily in qualifying employer se-
curities.  The term “qualifying employer securities” means any employer security within the meaning of Code section 409(l).  Under section 
409(l)(1), the term “employer securities” means common stock issued by the employer (or by a corporation which is a member of the same 
controlled group) which is readily tradable on an established securities market within the meaning of section 1.401(a)(35)-1(f)(5).  If there 
is no stock meeting the requirements of section 409(l)(1), the stock must satisfy section  409(l)(2) or section 409(l)(3).

Page 12                                                                          CYCLE A Submission Period – 02/01/2016 – 01/31/2017
54.4975-11(a)(2)
4975 (e)(7) (A)
4975(e)(8)
54.4975-11(b)
409(l)
1.401(a)(35)-1(f)(5)
Notice 2011-19

Line b. Regulation 54.4975-7(b)(4) provides that the proceeds of an exempt loan must only be used for: (i) the acquisition of qualifying 
employer securities, (ii) to repay such loan and/or, (iii) to repay a prior loan.
54.4975-7(b)(4)

Line c. Regulation 54.4975-7(b)(5) provides that the exempt loan must be without recourse against the ESOP and that the only assets 
that may be given as collateral on such loan are qualifying employer securities of two classes, (i) those acquired with the proceeds of an 
exempt loan, and (ii) those that were used as collateral on a prior exempt loan and repaid with the proceeds of the current exempt loan.
54.4975-7(b) (5)

Line d. Regulations 54.4975-7(b)(7) provides that the interest rate of the exempt loan must not be in excess of a reasonable rate of 
interest. The regulation further provides that all relevant factors will be considered in determining a reasonable rate of interest, including 
the amount and duration of the loan. Regulation 54.4975-7(b)(13) provides that the exempt loan must be for a definite period of time and 
cannot be payable at the demand of any person, except in the case of default. 
54.4975-7(b)(7) & (13)

Line e. The plan must provide that if a portion of the account is forfeited, qualifying securities are forfeited only after other assets.
54.4975-11(d)(4)

Line f. Regulation 54.4975-11(c) requires that the terms of an ESOP must provide for the use of a suspense account to hold qualifying 
employer stock purchased by the ESOP trust through an exempt loan until its release and allocation to participants’ accounts in the ESOP.
54.4975-11(c)

Line g. Regulation §54.4975-7(b)(8) provides that the plan must release employer securities from the suspense account either under the 
“general rule” or the “special rule”.

The “general rule” provides that for each plan year during the loan, the number of shares released must equal the number of shares held 
before the current year’s release, multiplied by a fraction with the principal and interest paid for the year being the numerator and the 
denominator being the sum of this amount plus the principal and interest to be paid for all future years.
The “special rule” provides for the release of employer securities from the suspense account using the above fraction but based solely on 
payments of principal. This rule may only be used if the term of the loan is for 10 years or less (including renewal or extension periods) 
and the interest is one that would be determined under a standard amortization table.
The plan must state which method it will use to release stock from the suspense account. If the plan incorporates both methods, it should 
also have language to state that once a method is chosen it cannot be changed during the period of the exempt loan, except to the extent 
that the method as described in the general rule has been violated. 
54.4975-7(b)(8)

Line h. ESOPs and certain defined contribution plans (see Code section 401(a)(22)) are subject to the requirements of section 409(e).  
If the employer has a class of securities that is required to be registered under Section 12 of the Securities and Exchange Act of 1934 
(“the Exchange Act”) or a class of securities that would be required to be registered except for the exemption from registration provided 
by Section 12(g)(2)(H) of the Exchange Act, Code §409(e)(2) states that the plan must provide each participant with the right to direct the 
voting of securities allocated to their account on all corporate matters.

If the employer does not have a registration- type class of securities, Code §409(e)(3) requires that the plan allow the participants to vote 
the shares in their account, but only with respect to the approval or disapproval of any of the following transactions:

1) corporate  mergers or consolidations,

2) the sale of all or substantially all of the corporation’s assets,

3) recapitalizations,

4) reclassifications,

5) liquidations, and

6) dissolutions.

It is the Service’s position that applicable state law would govern with respect to the right to direct the plan to vote allocated shares, in 

Page 13                                                                        CYCLE A Submission Period – 02/01/2016 – 01/31/2017
the case of non-registration type securities. Therefore, state law must provide for shareholder voting on those corporate matters before 
voting rights are passed through to the participants. In addition, Code §409(e)(5) provides for a special 1 vote for each participant rule for 
non-registration type class securities. This special rule allows each participant 1 vote with the trustee voting the shares held by the plan 
in proportion to the votes received.

For either a registration-type class or non-registration-type class of securities, the plan may provide that, if the plan trustee does not re-
ceive instructions on how to vote the particular shares, the trustee will vote those shares. See Revenue Ruling 95-57, 1995-57, 1995-2 
C.B. 62.

In addition, plans may or may not  “pass through” voting rights on unallocated shares (shares still in the suspense account) to participants. 
The plan could provide for the trustee to vote these shares. The plan could also provide that unallocated shares as well as allocated 
shares are voted in proportion to the allocated shares for which directions have been received. The Department of Labor has held that the 
responsibility for the voting of unallocated shares should rest with the plan trustee. The plan trustee, however, may follow plan provisions 
only to the extent permitted by ERISA §404(a)(1)(D) (i.e. insofar as plan provisions are consistent with Titles I and IV of ERISA).
409(e)(2) – (5)
Revenue Ruling 95-57
401(a)(22)

Line i. Stock bonus plans and ESOPs are subject to Code section 409(h).  Section 409(h)(1)(A) provides that the participant must be 
given the right to demand that their entire distribution be in the form of employer securities. If the employer securities are not readily trad-
able on an established market, the employee has the right to require that the employer repurchase the employer securities under a fair 
valu¬ation formula. Code §409(h)(1)(B). “Readily tradable on an established market” has the same meaning as “readily tradable on an 
established securities market” in  section 1.401(a)(35)-1(f)(5) of the regulations.

Code section 409(h)(2)(B) provides that if the employer is an S corporation or if the employer’s corporate charter (or bylaws) restricts 
ownership of substantially all outstanding employer securities to employees or to a trust under a qualified plan, the participant does not 
have to be given the right to demand a distribution in the form of employer securities. In either case, such plan may distribute employer 
securities subject to the requirement that such securities may be resold to the employer in conformance with section 409(h)(1)(B).

A right to demand a distribution in the form of employer securities does not have to be given if the securities were subject to the right of 
diversification under section 401(a)(28)(B) or subparagraph (B) or (C) of section 401(a)(35) and the participant had previously made an 
election to diversify. Code section 409(h)(7) and Notice 88-56, Q&A-14.
409(h)(1)(A)
409(h)(1)(B)
409(h) (2) (B)
409(h) (7)
1.401(a)(35)-1(f)(5)
Notice 2011-19
401(a)(23)

Line j. Stock bonus plans and ESOPs are subject to Code section 409(h)(1)(B),  Section 409(h)(1)(B) requires that participants who 
receive a distribution of stock that is not “readily tradable on an established market” must have the right to require the employer to repur-
chase the employer securities under a fair valuation formula (“put option”).   
  
The term “readily tradable on an established market” has the same meaning as “readily tradable on an established securities market” in 
section 1.401(a)(35)-1(f)(5) of the regulations.

The ESOP must provide that the put option is exercisable during two periods. The first one is for at least 60 days following the date of 
distribution and the second one is for at least 60 days in the following plan year. Code §409(h)(4).

The plan must also provide that if the participant receives a total distribution which is required to be repurchased by the employer, the 
employer must make payments at least as rapid as substantially equal periodic payments (at least annually) over a period beginning not 
later than 30 days after exercise of the put option and not exceeding 5 years. The employer must also provide adequate security and pay 
reasonable interest on any unpaid amount. Code §409(h)(5).

If the exempt loan is repaid, or if the plan ceases to be an ESOP, the put option requirements must continue to exist with respect to distri-
butions that were acquired with the exempt loan. Section 54.4975-11(a)(3)(ii). Also securities acquired by an ESOP with an exempt loan 
may not be subject to a pre-existing put, call or other option, or buy-sell or similar arrangement while held by or distributed from the plan. 
Section 54.4975-7(b)(4). However, this provision does not override the put option requirement for securities that are not publicly traded .
409(h)(4)
409(h)(5)
54.4975-7(b) (10)
54.4975-11(a) (3) (ii)
401(a)(23)
1.401(a)(35)-1(f)(5)
Notice 2011-19

Page 14                                                                         CYCLE A Submission Period – 02/01/2016 – 01/31/2017

Line k. Section 401(a)(28)(C) requires a plan to provide, with regard to activities carried on by a plan, that valuations of employer securi-
ties which are not readily tradable on an established securities market are to be made by an independent appraiser.  “Readily tradable on 
an established securities market” is defined in section 1.401(a)(35)-1(f)(5) of the regulations. An “independent appraiser” is an appraiser 
who meets requirements similar to the requirements of the regulations under section 170(a)(1).
401(a)(28)(C)
1.401(a)(35)-1(f)(5)
Notice 2011-19

Line l. Code section 401(a)(28)(B) provides that each qualified participant in a plan may elect, within 90 days after the close of each plan 
year in the qualified election period, to direct the plan with regard to the investment of at least 25 percent of the participant’s plan account. 
The account balance subject to the diversification election is increased to 50 percent in the final year of the election period. Q&A-9 of 
Notice 88- 56,1988-1 C.B. 540, provides that the portion of a qualified participant’s account subject to the diversification election in all 
years of the qualified election period (other than the final year) is equal to (1) 25 percent of the number of shares of employer securities 
acquired by the plan after December 31, 1986, that have ever been allocated to a qualified participant’s account, less (2) the number of 
shares of employer securities previously diversified pursuant to a diversification election made after December 31, 1986.

A “qualified participant” is any employee who has completed at least 10 years of participation in the plan and has attained age 55. The 
“qualified election period” is the 6 plan year period beginning with the later of (1) the first plan year in which the individual first becomes a 
qualified participant, or (2) the first plan year beginning after December 31, 1986.

There are three methods by which a plan can satisfy the diversification requirement. The first two are statutory and appear in section 
401(a)(28)(B). First, the plan provides that the portion of the participant’s account subject to the diversification election is distributed within 
90 days after the period in which the election can be made. Second, the plan offers at least three investment options to each participant 
making the diversification election, and within 90 days after the election period ends, the plan invests the portion of the amount subject to 
the diversification election. Q&A-13 of Notice 88-56 provides a third method by which a plan can satisfy the diversification election. The 
plan offers a participant the option to direct the plan to transfer the portion of the account subject to the diversification election to another 
qualified defined contribution plan of the employer that offers at least three investment options. This transfer must be made no later than 
90 days after the end of the election period.

Note that ESOPs which are “applicable defined contribution plans” as defined in Code § 401(a)(35)(E) are subject to the diversification 
rules of Code § 401(a)(35) and not Code § 401(a)(28)(B). See Part III, line l.  
401(a)(28)(B)
401(a)(35)
Notice 88-56, Q&A 13

Line m. Section 409(o) provides that an ESOP participant who is entitled to receive a distribution can elect, with the consent of his or her 
spouse as required by section 401(a)(11) and 417, to commence the distribution of his or her account balance not later than one year after 
the close of the plan year (1) in which the participant separates from service by reason of normal retirement age, disability, or death, or 
(2) which is the 5th plan year following the plan year in which the participant otherwise separates from service, as long as the participant 
is not reemployed by the employer before this distribution is required to begin.

This election for distribution does not apply to any employer securities acquired with the proceeds of a loan to an ESOP until the close 
of the plan year in which the loan is repaid in full. Unless the participant elects otherwise, the distribution of the account balance must be 
in substantially equal periodic payments (made at least annually) over a period of not greater than five years. If the participant’s account 
balance exceeds $800,000 (as adjusted for cost-of living increases), the distribution period is increased, unless the participant elects 
otherwise, to five years plus one additional year (up to five additional years) for each $160,000 (or fraction thereof) by which the balance 
exceeds $800,000. 
409(o)

Line n. Code §415(c)(6) and Regulation 1.415(c)-1(f)(3) provide a special rule that is used in determining annual additions made to an 
ESOP maintained by a C corporation. The rule provides that if not more than one-third of the employer contributions to an ESOP for a 
plan year are allocated to the accounts of participants who are highly compensated employees (within the meaning of Code §414(q)), all 
forfeitures of employer securities acquired with the proceeds of an exempt loan and all employer contributions used to pay interest on an 
exempt loan which are charged against the participant’s account are eliminated from the computation of annual additions.
415(c)(6)
1.415(c)-1(f)(3)

Line o. Code section 409(n) provides that a plan to which section 1042 applies  shall provide that no portion of the assets of the plan 
attributable to (or allocable in lieu of) employer securities acquired by the plan in a sale to which section 1042 applies may accrue (or be 
allocated directly or indirectly under any qualified plan of the employer:  (A) during the nonallocation period for the benefit of any taxpayer 
(and individuals related to the taxpayer within the meaning of section 267(b)) who makes an election under section 1042(a) with respect 
to employer securities, or (B) for the benefit of any other person who owns (after application of section 318(a)) more than 25 percent of (i) 
any class of outstanding stock of the corporation which issued such employer securities or of any corporation which is a member of the 
same controlled group of corporations, or (ii) the total value of any class of outstanding stock of any such corporation.  For purposes of 
(B), section 318(a) is applied without regard to the employee trust exception in section 318(a)(2)(B)(i).

Page 15                                                                     CYCLE A Submission Period – 02/01/2016 – 01/31/2017

Code section 409(n)(3)(B) states that a person is treated as failing to meet the 25 percent ownership requirement if such person fails this 
requirement at any time during the 1-year period ending on the date of sale of qualified securities to the plan or on the date  as of which 
qualified securities are allocated to participants in the plan.

Code section 415(n)(3)(C) defines the term “nonallocation period” as the period beginning on the date of the sale of the qualified securities 
and ending on the later of (i) the date which is 10 years after the date of sale, or (ii) the date of the plan allocation attributable to the final 
payment of acquisition indebtedness incurred in connection with the sale.

See Code section 409(n)(3)(A) for rules regarding lineal descendants.
409(n)

Line p. Section 409(p) was enacted as part of EGTRRA effective for plan years after 12/31/04, but immediately effective for S corporation 
ESOPs established on or before 3/14/01. The intent of this law is to limit the tax deferrals provided by an S corporation ESOP to those 
situations where there is broad-based employee coverage under the ESOP and the ESOP benefits rank-and-file employees as well as 
highly compensated employees and historical owners.

Pursuant to Code §409(p)(1),an ESOP holding stock in an S corporation stock must provide that no portion of the assets of the plan 
attributable to (or allocable in lieu of) such stock may during a “nonallocation year”, accrue (or be allocated directly or indirectly under 
any plan of the employer meeting the requirements of section 401(a) for the benefit of any “disqualified person”. Such assets held in the 
accounts of disqualified persons in a nonallocation years are “prohibited allocations”. Note that there is a prohibited allocation to the extent 
that employer securities consisting of stock in an S corporation owned by the ESOP and any assets attributable thereto are held under 
the ESOP for the benefit of a “disqualified person” during a nonallocation year. This includes all such assets allocated to the disqualified 
persons account in any previous year and held in the disqualified persons account in the nonallocation year. Section 1.409(p)-1(b)(2).

Prohibited allocations are deemed to be distributed and includable in income tax. In addition, IRC 4979(A) imposes on the S corporation 
a 50% excise tax on the “prohibited allocations”. That section also imposes a 50% excise tax on the value of the “synthetic equity” owned 
by “disqualified persons” during a nonallocation year, whether a prohibited allocation has occurred or not.
409(p)(1)
409(p)(2)
1.409(p)-1(b)(1)
1.409(p)-1(b)(2)(i)-(iv)

Line q. A “nonallocation year” is any ESOP plan year where, at any time during the year, “disqualified persons” own directly or through 
attribution, 50% of the number of outstanding shares of the S corporation. The determination of whether a nonallocation year has occurred 
takes into account all the shares of the S corporation whether held in the ESOP or not. Section 409(p)(5) provides that in the case of a 
person who owns synthetic equity, the shares of stock on which such synthetic equity is based on is treated as outstanding stock of the 
S corporation and deemed owned shares of that individual. Section 409(p)(3).

Under section 409(p)(4) a disqualified person is one who is either a member of a 20% shareholder group or is a 10% shareholder taking 
into account synthetic equity owned by the individual if such addition causes the individual to become disqualified.

A person is a member of a 20% shareholder group if the number of “deemed-owned shares” of the person and the person’s family is at 
least 20% of the total S corporation shares held by the ESOP.

The term “deemed-owned shares”, under section 409(p)(3)(C), is the sum of:

1) stock allocated to an account of an individual by the ESOP and

2) an individual’s share of unallocated stock held by the ESOP. IRC section 409(p)(4)(C)(ii) provides that a person’s share of unallocated 
S corporation stock held by such plan is the amount of the unallocated stock which would be allocated to such person if the unallocated 
stock were allocated to all participants in the same proportions as the most recent stock allocation under the plan.

A person is a 10% shareholder if the person is not a member of a 20% shareholder group and the number of the person’s “deemed-owned 
shares” is at least 10% of the total S corporation shares held by the ESOP.

The determination as to whether a participant is a 10% shareholder must also take into account that individual synthetic equity shares 
of the S corporation (see discussion of synthetic equity, below), if by doing so causes the person to be disqualified. Section 409(p)(5). In 
this regard synthetic equity issued by the S corporation to other individuals is not taken into consideration. The individuals total shares 
(deemed-owned and synthetic equity shares) are compared with the total number of deemed owned shares and the individual’s synthetic 
equity shares. Section 1.409(p)-1(d)(1)

For purposes of determining ownership, the attribution rules of IRC section 318 apply, modified with the exception that the members of an 
individual’s family shall include members of the family described in IRC section 409(p)(4)(D). See IRC section 409(p)(3)(B).

Family members will include the

Page 16                                                                           CYCLE A Submission Period – 02/01/2016 – 01/31/2017

ii) individual’s spouse,

iii)  ancestors or lineal descendant of the individual or the individual’s spouse,

iiii)  brother or sister of the individual or the individual’s spouse and any lineal descendant of the brother or sister, and

ivi)  the spouse of any individual described in (ii) or (iii). 

Section 409(p)(6)(C) defines synthetic equity as any stock option, warrant, restricted stock or similar right that gives the holder the right 
to acquire or receive stock of the S corporation. It also includes a stock appreciation right, phantom stock unit, or similar right to a future 
cash payment based on the value of such stock or appreciation in such value. Section 1.409(p)-1(f)(2)(iv), synthetic equity is defined to 
include non-qualified deferred compensation. This includes any remuneration for services rendered to the S corporation to which IRC 
404(a)(5) applies.

The number of synthetic equity shares attributed to a stock option is based on the number of shares that are subject to that option. For 
example, an option to purchase 10 shares of S Corporation stock becomes 10 shares of synthetic equity without regard to the option price. 
The number of synthetic equity shares based on shares of stock but for which payment is made in cash or other property (e.g., phantom 
stock units), the number of synthetic equity shares is equal to the number of shares having a fair market value equal to the cash or other 
property paid.

In the case of synthetic equity that is not determined by reference to shares (i.e., nonqualified deferred compensation), the person entitled 
to the synthetic equity is treated as owning the number of shares equal to the present value of the synthetic equity divided by the fair 
market value of a share of the S Corporation’s stock as of the same date. Section 1.409(p)-1 of the regulations, generally effective 1/1/05, 
provides the following special rules in regards to synthetic equity:

i. The number of synthetic equity shares based on nonqualified deferred compensation may be deter-mined on the first day of the 
ESOP’s plan year or any other reasonable determination date. Section 1.409(p)-1(f)(4)(iii)(B)(1)

ii. An ESOP may provide that the number of synthetic equity shares treated as owned on a determination date may remain constant 
from that date until the date immediately preceding the third anniversary of the determination date. Section 1.409(p)-1(f)(4)(iii)(B)(2).

iii. The number of shares otherwise determined is ratably reduced to the extent that S corporation shares are owned outside the ESOP. 
409(p)(3)-(5)
409(p) (6) (C)
1.409(p)-1(c)(1), (2)
1.409(p)-1(d)(1),(2)(i)-(iv)
1 .409(p)-1(e)
1.409(p)-1(f)(1),(2)(i), (ii) & (iv)
1 409(p)-1(f) (4) (iii) (B) (1)&(2)
1 .409(p)-1(f) (4) (iv)

Line r.  Code section 404(k) provides a deduction, in addition to the section 404(a) deduction, for applicable dividends paid on applicable 
employer securities of a C corporation held by an ESOP. With regard to the employer taking a deduction under section 404(k), the plan 
must provide for the treatment of dividends in one of the four ways set forth in section 404(k)(2).

Code section 404(k)(2)(A) provides that the term “applicable dividend” means any dividend which, in accordance with plan provisions –
(i) is paid in cash to plan participants or their beneficiaries;
(ii)  is paid to the plan and is distributed in cash to plan participants or their beneficiaries not later than 90 days after the close of the plan 
year in which paid;
(iii)  is, at the election of such participants or their beneficiaries, (I) payable as provided in (i) or (ii) above, or (II) paid to the plan and 
reinvested in qualifying employer securities, or
(iv)  is used to make payments on an exempt loan the proceeds of which were used to acquire the employer securities (whether or not 
allocated to participants) with respect to which the dividend is paid.

Code section 404(k)(2)(B) provides that a dividend described in (iv) above which is paid with respect to any employer security which is 
allocated to a participant shall not be treated as an applicable dividend unless the plan provides that employer securities with a fair market 
value of not less than the amount of such dividend are allocated to such participant for the year which such dividend would otherwise 
have been allocated to such participant.

Under section 404(k)(3), “applicable employer securities” means, with respect to any dividend, employer securities which are held on the 
record date for such dividend by an ESOP which is maintained by the corporation paying the dividend or any other corporation within the 
control group (as defined by section 409(l)(4)) of that corporation.
404(k)
Notice 2002-2

                                                                               CYCLE A Submission Period – 02/01/2016 – 01/31/2017

                                             Employee Benefit Plan

                                 Miscellaneous Provisions 
                        (Worksheet Number 4 – Determination of Qualification)
Instructions – All items must be completed. A “Yes” answer generally indicates a favorable conclusion is warranted, while a “No” 
answer indicates a problem exists. Please use the space on the worksheet to explain any “No” answer. See Publication 6392, 
Explanation Number 4, for guidance in completing this form. Note: Questions I.b. and II.a. and b. are not applicable to government 
plans, nonelecting church plans, and other plans described in IRC 410(c).
The technical principles in this worksheet may be changed by future regulations or guidelines
Name of plan

I. Merger and Termination Provisions                                                         Plan Reference        Yes No                           N/A
a. Does the plan expressly provide that upon plan termination or partial termination (or, 
in the case of a profit-sharing, stock bonus, or other plan described in Code section 
412(h), a complete discontinuance of contributions), a participant’s interest will be 
nonforfeitable? [0402]
b. Does the plan provide that after its merger, transfer of assets or liabilities, or 
consolidation, benefits will be no less than before the merger or consolidation or 
transfer if the plan then terminates? [0403]
c. If this plan is a defined benefit plan, have any of the participants in this plan been 
covered by another defined benefit plan of the employer which has been, or is to be, 
terminated with excess plan assets returned to the employer? [0405 or 0412 & 
0413] (If I.c. answer is “Yes,” complete (i))
(i) Have cash distributions or guaranteed annuity contracts been provided for all 
     accrued benefits of all participants in the terminating plan? [0406 or 0412 & 0413]
Note: If (i) is “No,” any favorable determination letter issued on this plan must be caveated. (See Part I., lines c. and d. of Explanation No. 4.)
d. If this plan is a defined benefit plan, has it received or transferred assets or 
liabilities, subject to Code section 414(i), in a transaction with another defined 
benefit plan which has been, or is to be, terminated with excess plan assets having 
been, or to be, returned to the employer? [0408 or 0412 & 0413] (If I.d. is “Yes,” 
complete (i) and (ii))
(i) Are the accrued benefits of all participants in this plan fully vested and 
     nonforfeitable as of the date of termination of the other plan? [0409 or 0412 & 
     0413]
(ii) Have guaranteed annuity contracts been purchased to provide for all accrued 
     benefits of all participants in this plan as of the date of termination of the other 
     plan? [0410 or 0412 & 0413]
Note: If (ii) is “No,” any favorable determination letter issued on this plan must be caveated. (See Part I., lines c. and d. of Explanation No. 4.)
e. If I.c. or I.d. is “Yes,” has the employer, in the past 15 years, previously received a 
reversion of assets upon termination of a defined benefit plan which covered some 
or all of the same employees who are covered by this plan? [0415]
II. Benefits                                                                                 Plan Reference        Yes No                           N/A
a. Does the plan prohibit the assignment or alienation of an employee’s interest that is 
more than the statutory limits? [0421]
b. Do benefits under the plan begin, unless the participant otherwise chooses in This form is provided as an example only and should not be 
writing, no later than the 60th day after the latest of the close of the plan year in 
which (1) the participant either reaches age 65 or the plan’s normal retirement age, 
     completed or returned to the Internal Revenue Service.
whichever comes first, (2) occurs the 10th anniversary of the year in which the 
participant began participation under the plan, or (3) the participant terminates 
service with the employer? [0422]

Form 5626 (Rev. 4-2016) Catalog Number 42701W publish.no.irs.gov                      Department of the Treasury - Internal Revenue Service

Page 2                                                                           CYCLE A Submission Period – 02/01/2016 – 01/31/2017
II. Benefits - Continued                                                                    Plan Reference        Yes No N/A
c. If this is a pension plan, either: 
(i) are distributions not to be made before the participant reaches age 62 or, if 
       earlier, normal retirement age, terminates service, dies, or becomes disabled, or 
(ii) is this a defined benefit plan the terms of which, on or before December 8, 2014, 
       provided for a normal retirement age (applicable only with respect to an individual 
       who is a participant in the plan on or before January 1, 2017, or is an employee 
       at any time on or before January 1, 2017 of any employer maintaining the plan) 
       which is the earlier of— 
       A. an age otherwise permitted under ERISA section 3(24), or 
       B. the age at which a participant completes the number of years (not less than 30 
       years) of benefit accrual service specified by the plan? [0424]
d. If the plan provides an early retirement benefit for participants who meet certain age 
and service requirements, does it provide that a participant who meets the service 
requirement, but separates from service before meeting the age requirement, will be 
entitled to receive the benefit when the age requirement is satisfied? [0425]
e. Does the plan allow distributees to elect to have eligible rollover distributions 
transferred directly to an eligible retirement plan? [0426]
f.  (Complete only if the plan provides for mandatory distributions) Does the plan 
provide that, in the event of a mandatory distribution greater than $1,000 where the 
participant does not elect to have such distribution paid directly to an eligible 
retirement plan specified by the participant in a direct rollover or to receive the 
distribution directly, that the plan administrator will pay the distribution in a direct 
rollover to an individual retirement plan designated by the plan administrator? [0427]
g. Does the plan include amounts attributable to rollover contributions in determining 
whether the mandatory distribution is greater than $1,000? [0428]
h. Are the survivors of any participants who die while on military service entitled to any 
additional benefits that would have been provided under the plan had the participant 
resumed employment and then terminated employment on account of death? [0429]
i.  Does the plan allow a nonspouse designated beneficiary to directly roll over any 
portion of a plan distribution to an inherited IRA? [0430]
III. General Qualification Issues                                                           Plan Reference        Yes No N/A
a. Does the trust prohibit the trust funds’ diversion or a return of employer contributions 
except for those permitted by the statute or Rev. Rul. 91-4? [0431]
b. Does the plan provide that an employee’s right to his or her normal retirement 
benefit is nonforfeitable on attainment of normal retirement age (as defined in Code 
section 411(a)(8))? [0432]
c. If the plan is a profit-sharing plan, are employer contributions allocated to 
participants’ accounts under a predetermined formula? [0433]
d. If the plan is a pension plan, does it provide for definitely determinable benefits? 
[0434]
e. If the plan is a defined benefit plan, does it expressly state the actuarial 
assumptions (for example, interest and mortality) or other methods (such as the 
conversion rates applied in a particular insurance contract) that will be used to 
determine the amount or level of any optional forms that are the actuarial equivalent 
of the normal retirement benefit payable under the plan? [0436]
f.  Are death benefits provided by the plan “incidental” within the meaning of section This form is provided as an example only and should not be 
1.401-1(b)(1) of the Income Tax Regulations, taking into account the QJSA and the 
QPSA, if required, under Code section 401(a)(11)? [0437]
       completed or returned to the Internal Revenue Service.
g. If the plan is a pension or annuity plan that includes a section 401(h) account for 
retiree medical benefits, does the plan limit the amount of contributions to such 
account, when added to actual contributions for life insurance, to the 25 percent of 
the total actual contributions made to the plan (other than contributions to fund past 
service) after the later of the adoption or effective date of the section 401(h) 
arrangement? [0438]
Form 5626 (Rev. 4-2016)   Catalog Number 42701W            publish.no.irs.gov        Department of the Treasury - Internal Revenue Service

Page 3                                                                              CYCLE A Submission Period – 02/01/2016 – 01/31/2017
III. General Qualification Issues - Continued                                                    Plan Reference         Yes No N/A
h. Has the plan requested consideration under section 420? (If “Yes,” see section 16 
and appendix of Rev. Proc. 2007-6, 2007-1 I.R.B.189.)
i.  If the plan is a defined contribution plan, is there a provision for valuation of the trust 
assets annually and adjusting participants' accounts accordingly? [0439]
j.  If any corrective amendment made after the end of a plan year is being taken into 
account for purposes of determining whether the plan satisfies the minimum 
coverage or nondiscrimination requirements for such year, have the conditions 
permitting the amendment to be given retroactive effect been satisfied? [0440]
k. If the plan allows employees to make voluntary employee contributions to a 
separate account or annuity established under the plan which meets the applicable 
requirements of section 408 (traditional IRA) or section 408A (Roth IRA), does the 
plan (i) restrict the commingling of deemed IRA assets with non-plan assets and (ii) 
provide that the trust must maintain a separate account for each deemed IRA, if 
deemed IRAs are held in a single trust that includes the defined contribution plan? 
[0441]
l.  Is the plan a defined contribution plan which holds any publicly traded employer 
securities? If it is, does it meet the diversification requirements of section 401(a)(35)
(B), (C), and (D) and regulations? Note that these requirements do not apply to an 
ESOP if there are no contributions to the ESOP that are subject to section 401(k) or 
401(m). For those ESOPs, see question V.l. Note also that these requirements do 
not apply to certain one-participant plans; see section 401(a)(35)(E)(iii). [0442]
m. Is the plan a defined contribution plan (other than a profit-sharing plan) established 
     by an employer whose stock is not readily tradable on an established securities 
     market within the meaning of section 1.401(a)(35)-1(f)(5)? If yes, after acquiring 
     securities of the employer, do securities of the employer constitute more than 10 
     percent of the total assets of the plan? (If yes, see Line h in Part V.)
n. Is the plan a stock bonus plan? (If yes, go to Lines I, j and m in Part V.)
IV. Compensation Limit                                                                           Plan Reference         Yes No N/A
a. Does the plan limit the compensation that may be taken into account in determining 
benefits or contributions on behalf of any employee to no more than the annual 
compensation limit? [0443]
b. If this is a defined benefit plan, does the plan determine a section 401(a)(17) 
employee’s accrued benefit by applying the fresh-start rules? [0444]
V. Amendments Relating to ESOPs                                                                  Plan Reference         Yes No N/A
a. Does the plan document formally designate the plan as an ESOP (Reg. 54.4975-11
(a)(2)) [0445] and does the plan state that it is designed to invest primarily in 
“qualifying employer securities,” which, under Code section 409(l)(1), means 
common stock issued by the employer (or by a corporation which is a member of 
the same controlled group) which is readily tradable on an established securities 
market within the meaning of section 1.401(a)(35)-1(f)(5)? If there is no such stock, 
do the employer securities meet the requirements of IRC 409(l)(2) or (3)? IRC 4975
(e)(7), 4975(e)(8) [0446]
b. Does the plan provide that the proceeds of an exempt loan must only be used for: (i) 
the acquisition of qualifying employer securities, (ii) to repay such loan, and/or (iii) to 
repay a prior loan? Reg. 54.4975-7(b)(4) [0447]
c. Does the plan provide that the exempt loan must be without recourse against the 
ThisESOP and thatformthe only assetsisthatprovidedmay be given as collateral onassuch loansanare example only and should not be 
qualifying employer securities of two classes, (i) those acquired with the proceeds of 
an exempt loan, and (ii) those that were used as collateral on a prior exempt loan 
       completed or returned to the Internal Revenue Service.
and repaid with the proceeds of the current exempt loan? Reg. 54.4975-7(b)(5) 
[0448]
d. Does the plan provide that the exempt loan must bear a reasonable interest rate 
and must be for a definite period of time and cannot be payable at the demand of 
any person, except in the case of default? Reg. 54.4975-7(b)(7) & (13) [0449]

Form 5626 (Rev. 4-2016)   Catalog Number 42701W           publish.no.irs.gov               Department of the Treasury - Internal Revenue Service

Page 4                                                                    CYCLE A Submission Period – 02/01/2016 – 01/31/2017
V. Amendments Relating to ESOPs - Continued                                                Plan Reference          Yes No                        N/A
e. Does the plan provide that if a portion of the account is forfeited, qualifying 
securities must be forfeited only after other assets? Reg. 54.4975-11(d)(4) [0450]
f.  Does the plan provide that the employer securities acquired by the ESOP with the 
proceeds of an exempt loan must be added to and maintained in a suspense 
account? Reg. 54.4975-11(c) [0451]
g. Does the plan provide for the release from encumbrance qualifying employer 
securities under either the “general rule” or “special rule”? Reg. 54.4975-7(b)(8) 
[0452]
h. If the employer has a registration-type class of securities as defined in IRC section 
409(e)(4), does the plan provide that each participant is entitled to direct the plan in 
the manner in which securities allocated to his account are to be voted? Code 
section 409(e)(2) [0453]  With regard to securities which are not a registration-type 
class, does the plan provide that each participant is entitled to direct the plan to vote 
the allocated securities with respect to the corporate matters specified in Code 
section 409(e)(3)? [0454]
i.  Does the plan, if sponsored by a C corporation, provide that a participant has a right 
to demand distributions in the form of employer securities? Code section 409(h)(1)
(A). [0455] If an S corporation ESOP does not give participants the right to demand 
employer securities, are the participants entitled to receive distributions in cash?
Code section 409(h)(2). [0456]
j.  If the employer securities are not readily tradable on an established securities 
market within the meaning of Reg. 1.401(a)(35)-1(f)(5), does the plan provide that a 
participant has the right to require that the employer repurchase employer securities 
under a fair valuation formula, and that the amount to be paid for a total distribution 
is paid in substantially equal periodic payments over not more than 5 years after the 
exercise of the put option, beginning not later than 30 days after the exercise of the 
put option, and with adequate security and reasonable interest on the unpaid 
amounts? Code sections 409(h)(1)(B) and 409(h)(5), Reg. 54.4975-7(b)(12), Notice 
2011-19. If the distribution is made in installments, does the plan provide that the 
initial payment is made not later than 30 days after the exercise of the put option?
Code section 409(h)(6), [0457]
k. Does the plan provide that valuation of employer securities which are not readily 
tradable on an established securities market within the meaning of section 1.401(a)
(35)-1(f)(5) are made by an independent appraiser pursuant to section 401(a)(28)
(C)? Notice 2011-19. [0458]
l.  Is the ESOP an “applicable defined contribution plan” as defined in section 401(a)
(35)? If yes, see question III.l. If not, does the plan provide that any employee who 
has completed at least 10 years of participation under the plan and has attained age 
55 is entitled to diversify a portion of his or her accounts’ investment in employer 
securities as required by section 401(a)(28)(B)? [0459]
m. Does the plan provide that a participant may elect to commence distribution of his 
     or her account balance after attaining normal retirement age, or after death, 
     disability or separation from service not later than required by section 409(o)? 
     [0460]
n. If the employer is a C corporation, does the plan provide that forfeitures of employer 
securities acquired with the proceeds of an exempt loan and interest payments on 
an exempt loan will be excluded from the Code section 415 limits only if no more 
than 1/3 of the employer contributions deductible under section 404(a)(9) for the 
year are allocated to highly compensated employees? Code section 415(c)(6) 
This[0461] form is provided as an example only and should not be 
o. Does the plan provide that the assets of the plan attributable to (or allocable in lieu completed or returned to the Internal Revenue Service.
of) employer securities acquired by the plan in a sale to which section 1042 applies 
cannot accrue (or be allocated directly or indirectly under any qualified plan of the 
employer) for the benefit of the persons specified in section 409(n)(1) for the period 
defined in section 409(n)(3)(C)? [0462]

Form 5626 (Rev. 4-2016)  Catalog Number 42701W         publish.no.irs.gov             Department of the Treasury - Internal Revenue Service

Page 5                                                           CYCLE A Submission Period – 02/01/2016 – 01/31/2017
V. Amendments Relating to ESOPs - Continued                                           Plan Reference          Yes No N/A
p. Does the ESOP provide that no portion of the plan assets attributable to (or 
allocable in lieu of) S corporation stock may, during a nonallocation year (as 
described in Code section 409(p)(3)), accrue (or be allocated directly or indirectly 
under any qualified plan of the employer) for the benefit of any disqualified person 
(as described in section 409(p)(4))? [0463]
q. For an S corporation ESOP, does the plan define the following terms: nonallocation 
year (in accordance with section 409(p)(3) and the associated regulations) [0464], 
disqualified person (in accordance with section 409(p)(4) and the associated 
regulations) [0465], deemed-owned shares (in accordance with section 409(p)(4)(C) 
and the associated regulations) [0466] and synthetic equity (in accordance with 
section 409(p)(6)(C) and the associated regulations)? [0467]

r.  Does the plan provide for the use of dividends in accordance with Code section 404
(k)(2)? [0468] 

In connection with Code section 404(k)(2)(iv), if a plan uses dividends that would 
have otherwise been allocated to a participant’s account, does the plan provide that 
employer securities with a fair market value of not less than the amount of such 
dividends are allocated to such participant’s account for the year which such 
dividends would otherwise have been allocated to such participant? [0469]

This form is provided as an example only and should not be 

       completed or returned to the Internal Revenue Service.

Form 5626 (Rev. 4-2016) Catalog Number 42701W publish.no.irs.gov                 Department of the Treasury - Internal Revenue Service

                                                                              CYCLE A Submission Period – 02/01/2016 – 01/31/2017
                                    Employee Plan Deficiency Checksheet
                                    Attachment Number 4
                                                    Miscellaneous
For IRS Use                         Please furnish the amendment(s) requested in the section(s) checked below.
     402            The plan must contain an express provision that, in the event of its termination or partial termination (or in the 
     I.a.           case of profit sharing, stock bonus, or other plan described in IRC section 412(h), a complete discontinuance of 
                    contributions), a participant’s interest under the plan as of such date is nonforfeitable to the extent funded. IRC 
                    section 411(d)(3) and Regs. section 1.411(d)-2.
     403            Section          of the plan should be amended to provide that in case of a merger or consolidation with, or 
     I.b.           transfer of assets or liabilities to, any other plan, each participant shall (if the plan then terminated) receive a 
                    benefit immediately after the merger, etc., which is equal to or greater than the benefit he or she was entitled to 
                    immediately before the merger, etc., (if the plan had then terminated). IRC sections 401(a)(12), 414(l), and Rev. 
                    Rul. 86-48, 1986-1 C.B. 216.
     405            Please advise whether any of the participants in this plan have been covered by another defined benefit plan of 
     I.c.           the employer which has been, or is to be, terminated with excess plan assets having been, or to be, returned to 
                    the employer.
     406            Please demonstrate whether or not lump sum distributions or guaranteed annuity contracts have been provided 
     I.c.(i)        for all accrued benefits of all participants in the terminating plan. Implementation Guidelines, Treasury News 
                    Release dated May 24, 1984.
     408            Please furnish information indicating whether the plan has received or transferred assets or liabilities subject to 
     I.d.           Code section 414(l), in a transaction with another defined benefit plan which has been, or is to be, terminated 
                    with excess plan assets having been, or to be, returned to the employer. Regs. section 1.414(l)-1 and 
                    Implementation Guidelines, Treasury News Release dated May 24, 1984.
     409            Section          of the plan should be amended to provide that the accrued benefits of all participants in this 
     I.d.(i)        plan are fully vested and nonforfeitable as of the date of termination of the other plan. Implementation 
                    Guidelines, Treasury News Release dated May 24, 1984.
     410            Please demonstrate whether or not guaranteed annuity contracts have been purchased to provide for all 
     I.d.(ii)       accrued benefits of all participants in this plan as of the date of termination of the other plan. Implementation 
                    Guidelines, Treasury News Release dated May 24, 1984.
     412, 413       An employer may not recover surplus assets in a transaction in which it splits an overfunded defined benefit 
     I.c.(i),       plan into two defined benefit plans, terminates one of the plans and receives the excess assets (“spinoff/ 
     I.d.(i) & (ii) termination” transaction), unless the following conditions are satisfied: (i) the benefits of all employees (including 
                    those employees covered by the ongoing plan) must be fully vested and nonforfeitable as of the date of 
                    termination, and (ii) all benefits accrued as of the date of termination for all employees (including those 
                    employees covered by the ongoing plan) must be provided for by the purchase of guaranteed annuity contracts. 
                    Please provide information demonstrating whether the conditions listed above have been satisfied. 
                    Implementation Guidelines, Treasury News Release dated May 24, 1984.
     415            Please advise whether the employer, in the past 15 years, previously received a reversion of assets upon 
     I.e.           termination of a defined benefit plan which covered some or all of the same employees who are covered by this 
                    plan. Regs. section 1.401-1(b)(2) and Implementation Guidelines, Treasury News Release dated May 24, 1984.
     421            Section          of the plan should be amended to provide that benefits under the plan may not be assigned 
     II.a.          or alienated except to the extent allowable under IRC sections 401(a)(13) and 414(p).
     422            Section          of the plan should be amended to provide that, unless the participant otherwise elects, 
     II.b.          benefits will commence within the time specified by IRC section 401(a)(14) and Regs. section 1.401 (a)-14.
     424            Section          of the plan should be amended to prevent distributions from being made before the 
     II.c.          attainment of age 62 or, if earlier, normal retirement age, termination of service, death or disability. Regs. 
This formsection 1.401-1(b)(1)(i),is providedRev. Rul. 56-693, 1956-2asC.B. 282,anand IRCexamplesection 401(a)(36).only and should not be 
     425            Since the plan provides for payment of an early retirement benefit upon the completion of a stated period of 
     completedII.d. service and the attainmentorofreturneda stated age, section to ofthethe plan mustInternalbe amended to provideRevenuethat a Service.
                    participant who meets the service requirement for early retirement upon termination of employment and who is 
                    entitled to receive a vested benefit, will commence to receive a benefit which is not less than the reduced 
                    normal retirement benefit upon satisfaction of the age requirement. IRC section 401(a)(14) and Regs. section 
                    1.401(a)-14(c).

Form 6043 (Rev. 4-2016)     Catalog Number 43037B          publish.no.irs.gov   Department of the Treasury - Internal Revenue Service

Page 2                                                                 CYCLE A Submission Period – 02/01/2016 – 01/31/2017
       426    Section          of the plan should be amended to provide that distributees may elect to have eligible rollover 
       II.e.  distributions paid in a direct rollover to an eligible retirement plan specified by the distributee. IRC section 401(a)
              (31) and Regs. section 1.401(a)(31)-1.
       427    Section          of the plan should be amended to provide for automatic rollovers of mandatory distributions 
       II.f.  of more than $1,000 if the distribute does not elect a direct rollover to an eligible retirement plan or to receive 
              the distribution directly. 401(a)(31)(B), Notice 2005-5, and Notice 2005-95.
       430    Section          of the plan should be amended to allow a nonspouse designated beneficiary to directly 
       II.i.  rollover any portion of a plan distribution to an inherited IRA. IRC section 402(c)(11).
       431    Section          of the plan should be amended to delete the provision for reversion of funds to the employer. 
       III.a. However, certain reversions are permitted if (1) the contribution is conditioned upon the initial qualification of the 
              plan, a timely determination letter request is filed, and the plan receives an adverse determination; or (2) the 
              reversion is due to a good faith mistake of fact; or (3) the contribution is conditioned on its deductibility under 
              section 404 of the Code. IRC section 401(a)(2), Regs. section 1.401-2(b)(1), and Rev. Rul. 91-4, 1991-1 C.B. 5.
       432    Section          of the plan should be amended to provide that an employee’s right to his or her normal 
       III.b. retirement benefit is nonforfeitable on attainment of normal retirement age, as defined in Code section 411(a)
              (8). IRC sections 411(a), 411(a)(8) and Regs. section 1.411(a)-7(b).
       433    A profit sharing plan must have a predetermined formula for allocating employer contributions that precludes 
       III.c. employer discretion. Section           of the plan should be amended accordingly. Regs. Section 1.401-1(b)
              (1)(ii).
       434    Section          of the plan should be amended to provide an express formula to determine employee 
       III.d. benefits which does not involve employer discretion. Regs. section 1.401-1 (b)(1)(i) and Rev. Rul. 74-385, 
              1974-2 C.B. 130.
       436    Section          of the plan should be amended to expressly state the actuarial assumptions (for example, 
       III.e. interest and mortality) or other methods (such as the conversion rates applied in a particular insurance contract) 
              that will be used to determine the amount or level of any optional benefit forms that are the actuarial equivalent 
              of the normal retirement benefit payable under the plan. IRC section 401(a)(25), Regs. section 1.401-1(b)(1)(i), 
              and Rev. Rul. 79-90, 1979-1 C.B. 155.
       437    The preretirement death benefits provided by the plan must be “incidental” within the meaning of Regs. section 
       III.f. 1.401-1(b)(1), taking into account the qualified preretirement survivor annuity, under Code section 401(a)(11).
              IRC section 401(a)(11) and 417(c), Regs. sections 1.401-1(b)(1)(i) &(ii), and Rev. Rul. 60-83, 1960-1 C.B. 157, 
              Rev. Rul. 60-84, 1960-1 C.B. 159, Rev. Rul. 66-143, 1966-1 C.B. 79, Rev. Rul.68-31, 1968-1 C.B. 151, Rev. 
              Rul. 70-611, 1970-2 C.B. 89, Rev. Rul. 74-307, 1974-2 C.B. 126 and Rev. Rul. 85-15, 1985-1 C.B. 132.
       438    Section          of the plan should be amended to provide that benefits under the plan may not be assigned 
       III.g. or alienated except to the extent allowable under IRC sections 401(a)(13) and 414(p).
       439    All defined contribution plans must provide for a valuation of investments held by the trust at least once a year 
       III.i. on a specified inventory date, in accordance with a method consistently followed and uniformly applied. The fair 
              market value on the inventory date is to be used for this purpose and the respective accounts of participants are 
              to be adjusted in accordance with the valuation. Rev. Rul. 80-155, 1980-1 C.B. 84.
       440    Please show that the amendment to the plan that was adopted on or that is proposed to be adopted, satisfies 
       III.j. the conditions described in section 1.401(a)(4)-11(g)(3) and (4) of the regulations relating to corrective 
              amendments that may be given retroactive effect for  purposes of satisfying the minimum coverage and 
              discrimination requirements.
       441    Section          of the plan should be amended to (choose on or both below, as applicable) (i) restrict the 
       III.k. commingling of deemed IRA assets with non-plan assets and (ii) provide that the trust must maintain a separate 
              account for each deemed IRA.
       442    The plan should be amended to comply with IRC section 401(a)(35). See Notice 2006-107, 2006-2 C.B. 1114, 
       III.l. for guidance and transitional rules.
This443       formSection is provided of the plan should be amendedasto limitanthe compensationexamplethat may be takenonlyinto account inand should not be 
       IV.a.  determining contributions on behalf of any employee to no more than $200,000 (as adjusted) (or the other 
       completed or returned to the Internal Revenue Service.applicable limits for plan years beginning before January 1, 2002). IRC section 401(a)(17) and Regs. section 
              1.401(a)(17)-1.
       444    The plan should be amended so that the accrued benefit of a section 401(a)(17) employee within the meaning 
       IV.b.  of section 1.401(a)(17)-1(e)(2)(i) of the regulations is determined under the rules described in section 1.401(a)
              (17)-1(e) of the regulations or indicate that there are no section 401(a)(17) employees. IRC section 401(a)(17) 
              and Regs. section 1.401(a)(17)-1(e).

Form 6043 (Rev. 4-2016) Catalog Number 43037B       publish.no.irs.gov           Department of the Treasury - Internal Revenue Service

Page 3                                                                       CYCLE A Submission Period – 02/01/2016 – 01/31/2017
       445  The plan should be amended to formally designate itself an ESOP.
       V.a.
       446  The plan should be amended to state that it is designed to invest primarily in qualifying employer securities and 
       V.a. define that term in accordance with IRC section 409(l) and section 1.401(a)(35)-1(f)(5) of the regulations. See 
            Notice 2011-19.
       447  The plan should be amended to provide that the proceeds of an exempt loan must only be used for: (i) the 
       V.b. acquisition of qualifying employer securities, (ii) to repay such loan and/or (iii) to repay a prior loan.
       448  The plan should be amended to provide that the exempt loan must be without recourse against the ESOP and 
       V.c. that the only assets that may be given as collateral on such loan are qualifying employer securities of two 
            classes, (i) those acquired with the proceeds of an exempt loan, and (ii) those that were used as collateral on a 
            prior exempt loan and repaid with the proceeds of the current exempt loan.
       449  The plan should be amended to provide that the exempt loan must bear a reasonable interest rate and must be 
       V.d. for a definite period of time and cannot be payable at the demand of any person, except in the case of default.
       450  The plan should be amended to provide that if a portion of the account is forfeited, qualifying securities must be 
       V.e. forfeited only after other assets.
       451  The plan should be amended to provide that the employer securities acquired by the ESOP with the proceeds of 
       V.f. an exempt loan must be added to and maintained in a suspense account in conformance with section 
            54.4975-11(c) of the regulations.
       452  The plan should be amended to provide for the release from encumbrance qualifying employer securities under 
       V.g. either the “general rule” or “special rule” as described in section 54.4975-7(b)(8) of the regulations.
       453  The plan should be amended to provide that, with respect to registration-type class securities, each participant 
       V.h. is entitled to direct the plan trustee in the manner in which securities allocated to his account are to be voted.
       454  The plan should be amended to provide that, with regard to securities which are not a registration-type class, 
       V.h. each participant is entitled to direct the plan trustee to vote the allocated securities with respect to the corporate 
            matters specified in IRC section 409(e)(3).
       455  The plan should be amended so that a participant has a right to demand distributions in the form of employer 
       V.i. securities as required by IRC section 409(h)(1)(A).
       456  The plan should be amended to provide that benefits may be distributed in cash or in employer securities in 
       V.i. accordance with IRC section 409(h)(2)(A) or (B), as applicable.
       457  Section          of the plan should be amended to provide that where a participant is entitled to a distribution 
       V.j. from the plan of securities that are not readily tradable on an established securities market within the meaning of 
            section 1.401(a)(35)-1(f)(5), the employer will repurchase the securities within the periods, and in accordance 
            with the methods described in IRC sections 409(h)(5) and (6).
       458  The plan should be amended to provide that valuations of employer securities which are not readily tradable on 
       V.k. an established securities market within the meaning of section 1.401(a)(35)-1(f)(5) of the regulations are made 
            by an independent appraiser, who meets requirements similar to the requirements of the regulations prescribed 
            under IRC section 170(a)(1). IRC section 401(a)(28)(C).
       459  The plan should be amended to provide that any employee who has completed at least 10 years of participation 
       V.l. under the plan and has attained age 55 is entitled to elect to diversify a portion of his or her account’s 
            investment in employer securities as required under IRC section 401(a)(28)(B).
       460  The plan should be amended to provide that a participant is entitled to elect to commence distribution of his or 
       V.m. her account balance not later than required by IRC section 409(o).
       461  The plan should be amended to provide in accordance with IRC section 415(c)(6) that forfeitures and interest 
       V.n. payments on an exempt loan may be excluded only if no more than 1/3 of the employer contributions deductible 
            under IRC section 404(a)(9) for the year are allocated to highly compensated employees (as described in IRC 
            section 414(q)).
This form is provided as an example only and should not be 
       462  Section          of the plan should be amended to provide that the assets of the plan attributable to employer 
       completedV.o. securities acquired byorthe planreturnedin a sale to which IRC sectionto1042theapplies cannotInternalaccrue for the benefitRevenueof Service.
            persons specified in IRC section 409(n) during the nonallocation period described in IRC section 409(n)(3)(C).
       463  The plan should be amended to provide (in accordance with IRC section 409(p)(1)) that no portion of the plan 
       V.p. assets attributable to (or allocable in lieu of) S corporation stock may, during a nonallocation year, accrue (or be 
            allocated directly or indirectly under any plan of the employer qualified under IRC section 401(a)) for the benefit 
            of any disqualified person as described in IRC section 409(p)(4).

Form 6043 (Rev. 4-2016) Catalog Number 43037B             publish.no.irs.gov               Department of the Treasury - Internal Revenue Service

Page 4                                                             CYCLE A Submission Period – 02/01/2016 – 01/31/2017
       464  The plan should be amended to include a definition for “nonallocation year” in conformance with IRC section 
       V.q. 409(p)(3) and section 1.409(p)-1(c) of the regulations.
       465  The plan should be amended to include a definition for “disqualified person” in conformance with IRC section 
       V.q. 409(p)(4)(A) and section 1.409(p)-1(d)(1) of the regulations.
       466  The plan should be amended to include a definition for “deemed-owned shares” in conformance with IRC 
       V.q. section 409(p)(4)(C) and section 1.409(p)-1(e) of the regulations.
       467  The plan should be amended to include a definition for “synthetic equity” in conformance with IRC section 409
       V.q. (p)(6)(C) and section 1.409(p)-1(f)(2) of the regulations.
       468  The plan should be amended to provide for the treatment of dividends in accordance with section 404(k)(2).
       V.r.
       469  The plan should be amended to provide that employer securities with a fair market value of not less than the 
       V.r. amount of the dividend that would have been allocated to a participant’s account are allocated to the 
            participant’s account for the year such dividend would have been allocated to the participant’s account.

This form is provided as an example only and should not be 

       completed or returned to the Internal Revenue Service.

Form 6043 (Rev. 4-2016) Catalog Number 43037B publish.no.irs.gov         Department of the Treasury - Internal Revenue Service