Department of the Treasury - Internal Revenue Service
Form 14568                                                                                                   OMB Number 
                                                                                                             1545-1673
(September 2017)      Model VCP Compliance Statement

Include the plan name, Applicant’s EIN and plan number on each page of the compliance statement, including attachments
Section I - Identifying Information
1. Applicant's name

2. Applicant's EIN (do not use SSN)                       3. Plan number

4. Plan name

Section II - Applicant's Description of Failures
Attach additional pages, as needed. Label the attachment “Section II. Applicant’s Description of Failures.” List and 
number each failure separately. If using the Form 14568 Schedules, specify the Schedules that are included and attach 
them to this compliance statement.

Section III - Applicant’s Description of the Proposed Method of Correction 
Attach additional pages, as needed. Label the attachment “Section III. Applicant’s Description of the Proposed 
Method of Correction.” Describe the correction method for each failure listed in Section II. If using the Form 14568 
Schedules, specify the Schedules that are included and attach them to this compliance statement.

Section IV - Applicant’s Proposed Procedures to Locate and Notify Former Employees or Beneficiaries
Attach additional pages, as needed. Label the attachment “Section IV. Applicant’s Proposed Procedures to Locate 
and Notify Former Employees or Beneficiaries.” Describe the methods that will be used to locate and notify former 
employees and beneficiaries, or provide an affirmative statement that no former employees or beneficiaries were affected 
by each failure listed in Section II or will be affected by the correction methods described in Section III. 

Section V - Applicant’s Proposed Revision to Administrative Procedures
Attach additional pages, as needed. Label the attachment “Section V. Applicant’s Proposed Revision to 
Administrative Procedures.” Include an explanation of how and why the failures arose and a description of the 
measures implemented (or will be implemented) to ensure that the same failures do not occur in the future. If using the 
Form 14568 Schedules, specify the Schedules that are included and attach them to this compliance statement.

Section VI - Requests Related to Excise Taxes, Additional Tax and Tax Reporting
The Applicant requests that the Internal Revenue Service (IRS) not pursue the following taxes under the Internal 
Revenue Code (IRC) (attach supporting rationale)
     Excise tax under IRC Section 4972 with respect to failures number
     Excise tax under IRC Section 4973 with respect to failures number
     Excise tax under IRC Section 4974 with respect to failures number
     Excise tax under IRC Section 4979 with respect to failures number
     Imposition of additional tax under IRC Section 72(t) with respect to failures number

Catalog Number 66138J                           www.irs.gov                              Form 14568 (Rev. 9-2017)
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.

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

Plan name

The Applicant requests that the IRS grant the following for plan loan failures that did not comply with IRC 
Section 72(p)
With respect to all loans described in this compliance statement, that a deemed distribution corrected pursuant 
to this VCP submission not be required to be reported on Form 1099-R and that repayments made by such 
correction not result in the affected participant having additional basis in the plan for purposes of determining the 
tax treatment of subsequent distributions from the plan.
With respect to all loans described in this compliance statement, that a deemed distribution be reported on Form 
1099-R with respect to affected participants for the year of correction instead of the year of the failure.
For one or more plan loans described in this compliance statement that it be permitted to report the loans as 
deemed distributions in the year of correction instead of the year of the failure. For other affected plan loans, the 
plan sponsor requests relief from reporting them as deemed distributions. Attach additional narrative details that 
explain why the relief should be granted and which specific loans will be receiving what type of special relief. 
Section VII - Enforcement Resolution (to be completed by IRS only)
The Applicant will neither attempt to nor otherwise amortize, deduct or recover from the IRS any portion of the paid user 
fee associated with this submission nor receive any Federal tax benefit on account of payment of such fee. 
The IRS will not pursue the sanction of revoking the tax-favored status of the plan under Sections 401(a), 403(b), 408(k) 
or 408(p) of the Internal Revenue Code (IRC) on account of the failures described in this compliance statement. This 
compliance statement considers only the acceptability of the correction methods including the revisions of administrative 
procedures described in the compliance statement and does not express an opinion as to the accuracy or acceptability of 
any calculations or other materials included with or provided at any time during the processing of the VCP submission. 
The reliance provided by this compliance statement is limited to the specific failures and years specified and does not 
provide reliance for any other failure or year. In no event may this compliance statement be relied on for the purposes of 
concluding that the plan or plan sponsor was not a party to an abusive tax avoidance transaction. This compliance 
statement should not be construed as affecting the rights of any party under any other law, including Title I of the 
Employee Retirement Income Security Act of 1974.  
This compliance statement expresses no opinion as to whether the plan otherwise satisfies the requirements of the IRC 
and is not a letter ruling or a determination letter within the meaning of Revenue Procedure 2017-1 (updated annually) 
and Revenue Procedure 2017-4 (updated annually).  
This compliance statement is conditioned on (1) there being no misstatement or omission of material facts in connection 
with the submission and (2) the completion of all corrections described in this compliance statement within one hundred 
fifty (150) days of the date of this compliance statement.

The IRS will treat the failure to adopt interim amendments or amendments for optional law changes, as described in 
this compliance statement as if they had been adopted timely for the purpose of making available the extended 
remedial amendment period set forth in Rev. Proc. 2007-44 and beginning on January 1, 2017, Rev. Proc. 2016-37, 
or its successors. However, this compliance statement does not constitute a determination as to whether any such 
plan amendments, as drafted, comply with the applicable changes in qualification requirements.

The IRS will treat the failure to timely adopt a written plan, as required under the IRC Section 403(b), final IRC 
Section 403(b) regulations and Notice 2009-3, as if it had been adopted timely for the purposes of making available 
the extended remedial amendment period set forth in Announcement 2009-89, Rev. Proc. 2013-22 and any future 
superseding guidance. However, this compliance statement does not constitute a determination as to whether the 
written plan, as drafted, complies with the applicable requirements associated with IRC Section 403(b) and the final 
IRC Section 403(b) regulations.

Catalog Number 66138J                                     www.irs.gov Form 14568 (Rev. 9-2017)

                                                                                                                Page 3
Applicant's EIN (do not use SSN)     Plan number

Plan name

With regard to failure number              (provided that no modification has been made to either the plan document or 
adoption agreement of the plan that would otherwise cause the employer to lose reliance on the plan’s opinion or 
advisory letter), the corrective amendment will not cause the plan to lose its status as a master or prototype plan or 
volume submitter plan and (provided that no modification has been made that would otherwise affect the employer’s 
eligibility for the six-year remedial amendment cycle) the employer will be allowed to remain within the six-year 
remedial amendment cycle described in Revenue Procedure 2007-44 on a continuing basis until the expiration of the 
next six-year remedial amendment cycle as provided in section 18.01 of Rev. Proc. 2007-44, or, if different, the 
deadline announced by the IRS, as provided in section 18.03 of that revenue procedure. In addition, the issuance of 
this compliance statement constitutes a determination of the effect of the corrective plan amendment on the 
qualification of the plan, and a subsequent filing of a determination letter request on such amendment will not be 
required until the expiration of the next six-year remedial amendment cycle.
The IRS will not pursue the following on account of the qualification failures described in this submission:
Excise tax under IRC Section 4972
Excise tax under IRC Section 4973
Excise tax under IRC Section 4974
Excise tax under IRC Section 4979
With respect to the overpayment failures described in this compliance statement that were corrected by 
removing improper distributions from the IRAs of the affected participants and returning those distributions to the 
plan, the IRS will not pursue           % of the 10% additional income tax under IRC Section 72(t).
(For certain VCP submissions made prior to January 1, 2017 only) A determination letter application, required by 
section 6.05 of Rev. Proc. 2013-12 (as modified by Rev. Proc. 2015-27) was included with this submission. This 
compliance statement is conditioned upon the issuance of a favorable determination letter for the plan as a result of 
determination letter application control number                  . If one or more of the failures described in this compliance 
statement are being corrected by proposed plan amendments the plan sponsor may adopt such amendments by the 
later of: (a) one hundred fifty (150) days following the date of the compliance statement or (b) ninety-one (91) days 
after the issuance of a favorable determination letter for the application. For governmental plans within the meaning 
of IRC Section 414(d), the deadline to adopt these amendments is further extended to the 91st day after the close of 
the first legislative session that begins more than one hundred twenty (120) days after a favorable determination 
letter is issued for the application.
With respect to the loan failures described in this compliance statement:
For all loans that are corrected by a corrective repayment to the plan or reamortization as described in this 
compliance statement: The IRS will not require deemed distributions under IRC Section 72(p) to be reported on 
Form 1099-R with respect to the participants affected by the failures, and repayments made pursuant to the 
correction of such loans will not result in an affected participant having additional basis in the plan for the 
purpose of determining the tax treatment of subsequent distributions from the plan to such participants.

For all loans that will be reported as deemed distributions. The IRS will require deemed distributions under IRC 
Section 72(p) to be reported on Form 1099-R with respect to the participants affected by the failures. However, 
the plan will be permitted to report deemed distributions on Form 1099-R in the year of correction, instead of the 
year of the failure.

Catalog Number 66138J                www.irs.gov                            Form 14568 (Rev. 9-2017)

                                                                              Page 4
Applicant's EIN (do not use SSN)                       Plan number

Plan name

         If the requested relief is not applied consistently to all loans. For loans where relief from issuing Form 1099-R is 
         applicable, all repayments made pursuant to the correction of the loans will not result in an affected participant 
         having additional basis in the plan for the purpose of determining the tax treatment of subsequent distributions 
         from the plan to the participants. For all other loans (or situations where affected participants do not choose to or 
         may not qualify for Form 1099-R relief), the IRS will require deemed distributions under IRC Section 72(p) to be 
         reported on Form 1099-R with respect to the participants affected by the failures. However, the plan will be 
         permitted to report the deemed distributions on Form 1099-R in the year of correction, instead of the year of the 
         failure.

Approved:

         Manager, Employee Plans Voluntary Compliance  
         Tax Exempt and Government Entities Division

Date

Catalog Number 66138J                                  www.irs.gov Form 14568 (Rev. 9-2017)