Department of the Treasury - Internal Revenue Service
Form 14568-A                                                                              OMB Number 
                      Model VCP Compliance Statement - Schedule 1: Interim 
(August 2016)                                                                             1545-1673
                                            Nonamender Failures
Include the plan name, Applicant’s EIN, and plan number on each page of the compliance statement, including attachments
Plan name

EIN                                                  Plan number

Instructions: 
(1) Schedule 1 can be used to report the correction of a failure to timely adopt good faith amendments or interim 
    amendments. A compliance statement issued for a Schedule 1 failure results in the corrective amendment being 
    treated as if it had been timely adopted for purposes of determining the availability of the extended remedial 
    amendment period. Thus, an Applicant may use Schedule 1 for the failure to adopt a required interim or 
    discretionary amendment ONLY if the corrective amendment was adopted before the expiration of the plan’s 
    extended remedial amendment cycle (as determined under Rev. Proc. 2007-44 and beginning on or after 1/1/2017, 
    Rev. Proc. 2016-37) for that amendment. If the corrective amendment was adopted after the expiration of the 
    remedial amendment cycle, then the Plan Sponsor can use Form 14568-B, Model VCP Compliance Statement 
    Schedule 2: Other Nonamender Failures and Failure to Adopt a 403(b) Plan Timely. 
(2) For submissions made under Rev. Proc. 2013-12, Schedule 1 may be used to correct the failure to timely adopt a 
    discretionary amendment required because of the plan’s implementation of an optional law change if the late 
    amendment was adopted before the expiration of the plan’s remedial amendment cycle that first included the 
    optional tax law change. If the amendment is not adopted by the deadline above, the result would be that the plan’s 
    operation would not be consistent with the plan’s terms and you can't use Schedule 1 to report that failure. 
(3) All corrective amendments required by Sections II and IV must be properly identified. Separate signed and dated 
    amendments should be submitted. If the amendments are incorporated into a signed and dated restated document, 
    the information in the VCP submission must specify the page and section of the document that contains the 
    amendment.

Section I - Identification of Failures
(1) Were the amendments used to correct the failures under this Schedule 1 adopted before the expiration of the 
applicable extended remedial amendment cycle? Check applicable box and follow applicable instruction below:
     Yes      No
If “Yes,” proceed to (2) of this Section I. 
If “No,” STOP - do NOT use this Schedule 1. 
In cases where late good faith amendments or interim amendments, are corrected after the expiration of the plan’s 
extended remedial amendment cycle, use Form 14568-B, Model VCP Compliance Statement Schedule 2: Other 
Nonamender Failures (and Failure to Adopt a 403(b) Plan Timely. For submissions made under Rev. Proc. 2013-12, 
discretionary amendments required because of the plan’s implementation of an optional law change that are corrected 
after the expiration of the plan’s extended remedial amendment cycle need to be presented as regular operational 
failures. 
(2) Were the amendments adopted to correct the failure to timely adopt interim amendments or amendments required to 
implement optional law changes (as defined in the current EPCRS revenue procedure)?
     Yes      No

If “Yes,” proceed to (3) of this Section I. 
If “No,” STOP - do NOT use this Schedule 1.

Catalog Number 66144N                       www.irs.gov                              Form 14568-A (Rev. 8-2016)
For Paperwork Reduction Act information see the current EPCRS Revenue Procedure.

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Plan name

EIN                                              Plan number

(3) The Applicant has indicated that the plan sponsor did not timely adopt amendments for the following: 
(List each statutory, regulatory, or other requirement for which the Plan was not timely amended, and specify for each 
such requirement the published cumulative list in which such requirement appears and the location of the corrective 
amendment in the documents included with the VCP submission (for example, by amendment number and paragraph 
number, or in the case of a restated plan, by page and section number). Do not use a general statement referring only 
to a cumulative list or statute. For instance, the following description would not be acceptable: “All interim amendments 
associated with the 20XX cumulative list [or the Pension Protection Act of 2006 (PPA)] were not timely adopted.”) 
 
(Attach additional pages as needed. Label the attachment “Form 14568-A, Section 1(3) Identification of Interim 
 Nonamender Failures” and include the plan name, Applicant’s EIN and plan number on each page.)

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

Section IV - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor 
encloses copies of the signed and dated amendments used to correct the failure(s) identified in Section I (3) of this 
Schedule 1 with this VCP submission.
Catalog Number 66144N                            www.irs.gov            Form 14568-A (Rev. 8-2016)