Revenue Procedure 2003-44, Appendix D

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Appendix D: Sample Formats for VCP Submissions

I. Sample Format for VCP Submission for Qualified Plan II. Sample Format for VCP Submission for Qualified Plan Failure to Amend Timely for Tax Legislation

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Appendix D

Sample Formats for VCP Submissions

I. Sample Format for VCP Submission for Qualified Plan

Plan Type, Group or Anonymous Submission

Identification of Failures

A complete description of the failures and the years in which the failures occurred, including (but not limited to):

1) Years in which the failure(s) occurred (including closed years)

2) Number of participants affected (may be estimated)

3) A description of the administrative procedures in effect at the time the failures occurred

4) Explanation of how and why the failures occurred

Description of Proposed Method of Correction

A narrative description of each step of the correction method, including (but not limited to):

1) the number of employees affected (may be estimated)

2) the expected cost of correction (may be estimated)

3) the years involved

4) calculations or assumptions used to determine the amounts needed for correction

5) a description of the methodology that will be used to calculate earnings or actuarial adjustments on any corrective contributions or distributions (indicating the computation periods and the basis for determining earnings or actuarial adjustments in accordance with section 6.02(4) of Rev. Proc. 2003-44)

6) Specific calculations, sufficient to demonstrate each aspect of the correction method proposed, for each affected employee or a representative sample of affected employees

7) The method that will be used to locate and notify former employees and beneficiaries, or an affirmative statement that no former employees or beneficiaries were affected by the failures or will be affected by the correction

8) If a submission includes a failure that refers to Transferred Assets and the failure occurred prior to the transfer, a description of the transaction (including the dates of the employer change and the plan transfer).

Description of Administrative Procedures

A description of the administrative measures that have been or will be implemented to ensure that the failure(s) will not recur

Statement regarding status of examination:

To the best of the Plan Sponsor's knowledge (1) the subject Plan is not currently under examination of either an Employee Plans Form 5500 series return or other Employee Plans examination, (2) the Plan Sponsor is not under an Exempt Organizations examination (that is, an examination of a Form 990 series return or other Exempt Organizations examination, and (3) neither the Employer nor any of its representatives have received verbal or written notification from the TEGE Division of an impending examination or of any impending referral for such examination, nor is the Plan in Appeals or litigation for any issues raised in such an examination.

Statement (if applicable) regarding status of any determination letter application not related to the VCP submission

Example: The Plan Sponsor applied for and has currently pending an application for a favorable determination letter with the Service filed on (insert date).

Sample Penalty of Perjury:

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

________________________________________________
Name and Title (Executed by Plan Sponsor)

Required Documentation:

___ Copy of plan document (or relevant plan provisions, i.e., those provisions relating to the failure(s) described in the submission.)

___ Copy of the first three pages of the most recently filed Form 5500 series return. (In the case of a terminated plan, the Form 5500 must be the one filed for the plan year prior to the plan year for which the Final Form 5500 return was filed.)

___ Power of Attorney (Form 2848), if applicable

Determination letter application

Where correction of a Qualification Failure includes correction of a Plan Document Failure or Demographic Failure, or an Operational Failure by plan amendment, as permitted under section 4.05, other than the adoption of an amendment designated by the Service as a model amendment or the adoption of a prototype or volume submitter plan for which the Plan Sponsor has reliance on the plan's opinion or advisory letter as provided in Rev. Proc. 2003-6, 2003-1 I.R.B. 191, please submit the following documents:

___ a copy of the amendment

___ the appropriate application form (i.e., Form 5300 series or Form 6406), and

___ Form 8717 and the appropriate user fee.

Assembling your submission

Please assemble your submission package in the following order:

1. Checklist-- Appendix C
2. Submission signed by the Plan Sponsor or Plan Sponsor's authorized representative
3. Form 5500
4. Determination application and associated documentation (if applicable)
5. Power of attorney
6. Penalty of perjury statement
7. Plan document

II. Sample Format for VCP Submission for Qualified Plan Failure to Amend Timely for Tax Legislation

Plan Type, Group or Anonymous Submission

Identification of Failures

1) Indicate which tax legislation is the subject of the submission: (check all that apply)

___ CRA	___ TEFRA/DEFRA/REA
___ GUST	___ TEFRA
___ UCA/OBRA '93	___ DEFRA
___ UCA	___ REA
___ OBRA '93	___ ERISA
___ TRA '86

2) Years in which the failure(s) occurred (including closed years)

3) A description of the administrative procedures in effect at the time the failures occurred

4) Explanation of how and why the failures occurred

Description of Proposed Method of Correction

Include appropriate Determination Letter Application (see "Required Documentation," below).

Description of Administrative Procedures

A description of the administrative measures that have been or will be implemented to ensure that the failure(s) will not recur

Statement regarding status of examination:

To the best of the Plan Sponsor's knowledge (1) the subject Plan is not currently under examination of either an Employee Plans Form 5500 series return or other Employee Plans examination, (2) the Plan Sponsor is not under an Exempt Organizations examination (that is, an examination of a Form 990 series return or other Exempt Organizations examination, and (3) neither the Employer nor any of its representatives have received verbal or written notification from the TEGE Division of an impending examination or of any impending referral for such examination, nor is the Plan in Appeals or litigation for any issues raised in such an examination.

Statement (if applicable) regarding status of any determination letter application not related to the VCP submission

Example: The Plan Sponsor applied for and has currently pending an application for a favorable determination letter with the Service filed on (insert date).

Sample Penalty of Perjury:

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

________________________________________________
Name and Title (Executed by Plan Sponsor)

Required Documentation:

___ Appropriate determination letter application form (i.e., Form 5300 series or Form 6406)

___ Copy of plan document in effect prior to proposed amendment

___ Copy of the proposed plan amendment

___ Form 8717 and determination user fee

___ Copy of determination letter most recently issued with respect to the plan

___ Any other materials required to be submitted with determination letter application (see Forms 5300, 6406, 5310 & Schedule Q, and 5303)

___ Copy of the first three pages of the most recently filed Form 5500 series return. (In the case of a terminated plan, include the Form 5500 filed for the plan year prior to the plan year for which the Final Form 5500 return was filed.)

___ Power of Attorney (Form 2848), if applicable

Assembling your submission

Please assemble your submission package in the following order:

1. Checklist-- Appendix C
2. Submission signed by the Plan Sponsor or Plan Sponsor's authorized representative
3. Form 5500
4. Determination application and associated documentation
5. Power of attorney
6. Penalty of perjury statement
7. Plan document

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Official location: 2003-25 I.R.B. 1051 (June 23, 2003)

Also online at https://benefitslink.com/IRS/revproc2003-44.pdf