Department of the Treasury - Internal Revenue Service
Form 14568-H          Model VCP Compliance Statement - Schedule 8:                                    OMB Number 
                                                                                                      1545-1673
(September 2017)                 Failure to Pay Required  
                            Minimum Distributions Timely
Include the plan name, Applicant’s EIN and plan number on each page of the submission.
Plan name

EIN                                                 Plan number

Section I - Identification of Failure (DO NOT USE THIS FORM IF PLAN BENEFITS DID NOT COMMENCE 
IN A TIMELY MANNER, AT THE PLAN’S NORMAL RETIREMENT AGE OR UPON THE PARTICIPANT’S 
DEATH. IF YOU CANNOT USE THIS FORM, ATTACH A WRITTEN NARRATIVE TO FORM 14568 AND 
PROVIDE THE NECESSARY INFORMATION REQUESTED BY THAT FORM.)
The plan identified above did not comply with the requirements of Section 401(a)(9) of the Internal Revenue Code (IRC) 
as required minimum distributions (RMD) were not paid in a timely manner or were less than what was required. When 
completing this table, affected plan participants should be counted separately under each year that an RMD was not 
made and not just in the first year of the failure. 
Calendar Years        Number of Participants        Total Amount of Missed Required Minimum Distributions  
                            Affected                                        (Do Not Include Earnings) 

Section II - Description of the Proposed Method of Correction
Defined contribution plan only - The plan will distribute the required minimum distributions (adjusted for earnings 
from the date of the failure to the date of distribution) to affected participants. For each affected participant, the 
required minimum distribution amount for each year in which the failure occurred will be determined by dividing the 
adjusted account balance on the applicable valuation date by the applicable distribution period. For this purpose, 
adjusted account balance means the actual account balance, determined in accordance with Section 1.401(a)(9)-5 
Q&A-3 of the Income Tax Regulations, reduced by the amount of the total missed minimum distributions for prior 
years. Earnings will be determined as follows

Defined benefit plan only - The plan will distribute the required minimum distributions plus an additional 
payment representing the loss of use of such amounts. (Note the additional payment is determined in 
accordance with the plan’s written terms for actuarial equivalence). The additional payment is determined as 
follows

Catalog Number 66153Y                               www.irs.gov                       Form 14568-H (Rev. 9-2017)
For Paperwork Reduction Act information see current EPCRS Revenue Procedure.

                                                                                                                     Page 2
Plan name

EIN                                                         Plan number

Defined benefit plan only – At the time of the proposed correction is the plan subject to any restriction on lump 
sum payments under IRC Section 436(d)? Include a copy of the plan’s most current actuarial certification of the 
plan’s Adjusted Funded Target Attainment Percentage (AFTAP) if “No” is checked. 
    Yes No

If "Yes", the plan sponsor will contribute to the plan, at the time of correction, an amount equal to the corrective 
distribution mentioned in this compliance statement as discussed in the current EPCRS revenue procedure.  
Section III - Request for Relief
A. The Applicant requests relief with regard to excise taxes under IRC Section 4974
    Yes No
          At least one affected participant is either an owner-employee (see IRC Section 401(c)(3)) or, if the plan 
          sponsor is a corporation, a 10 percent owner of such corporation.
If “Yes,” the Applicant submits the following explanation for its request for relief from the Section 4974 excise tax

Section IV - Change in Administrative Procedures
Include an explanation of how and why the failures arose and a description of the measures that have been (or will be) 
implemented to ensure that the same failures will not recur.

Section V - Enclosures
In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor 
encloses the following with this submission:
• A detailed explanation as to how you determined the user fee for this submission. If you qualify for a reduced fee, be 
sure to include the total number of plan participants with RMD failures. The reduced user fee does not apply if plan 
benefits did not commence in a timely manner at the plan’s normal retirement age or upon the participant’s death. 
• Specific calculations for each affected employee or a representative sample of affected employees.
• The sample calculations must be sufficient to demonstrate each aspect of the proposed correction method.

• For defined benefit plans, the calculations must illustrate the interest rate used to represent the loss of the use of the 
missed required minimum distributions.

• For defined contribution plans, the calculations must show how earnings were determined and their impact on the 
calculation of the corrective distributions.

• For defined benefit plans, a copy of the plan’s most current AFTAP certification if the Applicant has indicated that the 
plan is not under IRC 436(d) restrictions.

Catalog Number 66153Y                       www.irs.gov                            Form 14568-H (Rev. 9-2017)