Form 8950 Form 8950 Application for Voluntary Correction Program (VCP)

Version A, Cycle 2
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8950

Application for Voluntary
Correction Program (VCP)

Form
(August 2012)

OMB No. 1545-0202
For IRS Use Only

Department of the Treasury Under the Employee Plans Compliance Resolution System (EPCRS) For
the instructions and any other information, see www.IRS.gov/8950
Internal Revenue Service

Review the Procedural Requirements Checklist at the end of this application before submitting this application.
1a Name of plan sponsor (employer if single-employer plan)

1b Address of plan sponsor (if a P.O. Box, see instructions)

1c City

1d State

1e ZIP code

1f Country

1g Employer identification number

1h Telephone number

1i

Fax number

2a Name of applicant's representative. Attach Form 2848, Power of Attorney and Declaration of Representative, if applicable; if not
filing Form 2848, list an employee of the plan sponsor to contact should more information be needed (see instructions). If you
wish an individual to receive copies of correspondence related to this application and VCP submission, attach Form 8821, Tax
Information Authorization. This individual is not a representative and cannot be listed as a contact if more information is needed.

INTERNAL USE ONLY

Name of representative and representative's firm

DRAFT AS OF
August 6, 2012

2b Representative/contact person's address

2c City

2d State

2e ZIP code

2f Telephone number

2g Fax number

2h Email address

If more space is needed for any line item, attach additional sheets the same size as this form. Identify each additional sheet with the
plan sponsor’s name and EIN and identify the corresponding item.
Under penalties of perjury, I declare that I have examined this application and attached VCP submission, including accompanying
documents, and to the best of my knowledge and belief, they and the facts presented in support of this application and submission
are true, correct, and complete.

SIGN HERE ▶

Date ▶

This application must be signed by the owner or authorized employee of the plan
sponsor. In certain situations it may be a different person. See instructions under
Who May File and Lines 1a-f.
Type or print name

Type or print title

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 37769K

Form 8950 (8-2012)

Version A, Cycle 2
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Page 2

Form 8950 (8-2012)

3

Type of Voluntary Correction Program submission. (See instructions)
Check one:
Regular submission
Anonymous submission
Group submission
Other submission (as allowed by Revenue Procedure (Rev. Proc.) 20XX-XX, section 4.09)

4a Name of plan (plan name may not exceed 132 characters, including spaces):

INTERNAL USE ONLY

4b Enter 3-digit plan number
(see instructions)

4d Enter the dollar value of the
plan's assets (see instructions)

4c Enter month plan year ends
(MM) (see instructions)

4e Enter number of participants
(see instructions)

5

DRAFT AS OF
August 6, 2012

Indicate type of plan by entering the number from the list below:
01-Profit sharing (no 401(k))

11-SEP

02-401(k)

12-SARSEP

03-Money purchase

13-SIMPLE IRA

04-Defined benefit but not cash balance

14-Stock bonus

05-ESOP

15-KSOP

(Enter only one plan type)

06-Target benefit

16-Group submission defined contribution

07-403(b)

17-Group submission defined benefit

08-457(b)

99-Other (see instructions)

09-Cash balance or defined contribution/defined benefit hybrid
10-Government 414(d) defined benefit plan
20-Government 414(d) defined contribution

Form 8950 (8-2012)

Version A, Cycle 2
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Form 8950 (8-2012)

Yes
6

No
Are all qualification failures and correction methods in this VCP submission being resolved by the use of the
Appendix C Part II Schedules?
If “Yes,” please indicate the specific Schedules you are submitting from the list below by checking the
applicable boxes.

7a
7b

Schedule 1

Schedule 6

Schedule 11

Schedule 2

Schedule 7

Schedule 12

Schedule 3

Schedule 8

Schedule 4

Schedule 9

Schedule 5

Schedule 10

INTERNAL USE ONLY

Are you proposing to or have you corrected any section 401(a) plan document, operational or employer
eligibility failures (as defined in Rev. Proc. 20XX-XX, section 5.01(2)) with a retroactive plan amendment?
If 7a was “Yes,” have you concurrently submitted a determination letter application (see instructions)?

If 7a was “No,” please attach an explanation as to why such determination letter application was not
submitted.

DRAFT AS OF
August 6, 2012

7c

If 7a was “Yes,” indicate the plan's determination letter application cycle as determined by Rev. Proc.
2007-44 (or successor) that was in effect at the time of the failures and the date of this VCP submission. If
they are different, attach an explanation.

8

Has the plan or plan sponsor been party to an abusive tax avoidance transaction?
(see Rev. Proc. 20XX-XX, section 4.13(2))
If “Yes,” attach required statement per instructions.

9

Did the plan or plan sponsor engage in the diversion or misuse of plan assets? (see Rev. Proc. 20XX-XX,
section 4.12)

10

As of the date this application and VCP submission is to be mailed to the IRS, is the plan sponsor or the plan
under examination as defined in Rev. Proc. 20XX-XX, section 5.07?

11

Is the plan, at the time of this VCP submission, being considered in an unrelated determination letter
application request?
If “Yes,” include an attachment indicating the date the application was filed with the Service and the
determination application letter case number.

12

Have you previously filed a determination letter application for this plan with the IRS that was subsequently
withdrawn, or closed as incomplete due to a failure to submit requested information or as a result of a failure
to respond to a request for additional information?
If “Yes,” attach required statement per instructions.
Form 8950 (8-2012)

Version A, Cycle 2
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Fillable Fields need script inserted for Forced upper case. If adding fields, copy script from "exit".

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Form 8950 (8-2012)

Procedural Requirements Checklist
for Form 8950
Use this list to ensure that your submitted package is complete. While it is not mandatory that you complete this checklist,
failure to supply the appropriate information may result in a delay in the processing of the application and VCP submission.
1 Is Form 8951, Compliance Fee for Employee Plans Voluntary Correction Program Submission, attached to your
application?
2 Is the appropriate compliance fee (and photocopy of the compliance fee check) for your submission attached to Form
8951?
3 If appropriate, is Form 2848 or Form 8821 Authorization attached? For more information, see the Disclosure Request by
Taxpayer in the instructions and Rev. Proc. 2012-4 (or its successor). If there is no representative, enter the name and
contact information for the appropriate employee of the plan sponsor who can be contacted if additional information is
needed. See Lines 1a-f in the instructions.
4 Is the employer identification number (EIN) of the plan sponsor/employer (NOT the trust's EIN, nor anyone's SSN) entered
on line 1g?

INTERNAL USE ONLY

5 Is the application signed and dated? Please remember it must be signed by an authorized officer or owner of the plan
sponsor.
6 If you are submitting Appendix C Part I Model Compliance Statement or Appendix C Part II Schedules, have you used the
official versions of these documents that are located at www.irs.gov? Rev. Proc. 20XX-XX sections 11.01 and 11.02 do not
allow for the submission of modified versions of these documents.

DRAFT AS OF
August 6, 2012

7a If you answered “Yes” to line 7a, have you answered lines 7b and c and supplied the requested information?
7b If you answered “No” to line 7b, have you included a written explanation to support your answer as requested by line 7b?
7c If you answered “Yes” to line 7b, have you included a separate determination letter application package that includes
Form 8717 and either Forms 5300, 5307, or 5310, plus a separate check for the application user fee and its own copies of
plan documents, amendments, etc., required by the Form 5300 series application instructions?
8 If this is an anonymous VCP submission, have you included a signed statement from the plan sponsor's/employer's
representative indicating they have the legal authorization to make this submission and are willing and able to submit
Form 2848 to the IRS upon disclosure of the taxpayer's identity? See instructions and Rev. Proc. 20XX-XX, sections 10.10
and 11.08.
9 If this VCP submission involves an orphan plan, have you included appropriate documentation that establishes that this
application and VCP submission is being made by an eligible party? See instructions and Rev. Proc. 20XX-XX,
section 5.03.
NOTE: If you answered yes to line 6, items 10 through 17 on this procedural requirements checklist do not apply as they have been
incorporated into Appendix C Part II Schedules. All applicable items on each schedule need to be completed and you must include
the Enclosure items listed on the applicable Schedule with your VCP submission. The Appendix C Part II Schedules may be used with
Appendix C Part 1 Model VCP Submission Compliance Statement to resolve certain qualification failures. If you choose to combine
them, refer to the Appendix C Part II Sections under Appendix C Part 1 Model VCP Submission Compliance Statement Section II
(“Applicant's Description of Failures”), Section III (“Applicant's Description of Proposed Method of Correction”), and Section V
(“Applicant's Proposed Revision to Administrative Procedures”).
Form 8950 (8-2012)

Version A, Cycle 2
Fillable Field Font: Times; Size 10 pt; Color: Black;
Fillable Fields need script inserted for Forced upper case. If adding fields, copy script from "exit".

Page 5

Form 8950 (8-2012)

Procedural Requirements Checklist
for Form 8950 (Continued)
10 Have you included an attachment that explains how and why the described qualification failures arose? Be sure to include
a description of the applicable administrative procedures for the plan that were in effect at the time the described failures
occurred.
11 Have you included an attachment that provides a complete description for each qualification failure that is to be resolved
by this VCP submission? The narrative description should include the years in which the failures occurred, and the number
of employees affected by each failure.
12 Have you included an attachment that provides a detailed description of the method for correcting the failures that the Plan
Sponsor has implemented or proposes to implement to correct each failure described in this VCP submission? Each step
of the correction method must be described in narrative form and must include the specific information needed to support
the suggested correction method. See Rev. Proc. 20XX-XX, section 11.03, for additional details.
13 Have you included an attachment that provides a description of the administrative measures that have been or will be
implemented to ensure that the qualification failures described in this VCP submission do not recur? See Rev. Proc. 20XXXX, section 11.03.

INTERNAL USE ONLY

14 For failures involving corrective contributions or distributions, have you included an attachment that provides a detailed,
narrative description that explains the methodology you have used to determine lost earnings and how this is consistent
with EPCRS correction principles? See Rev. Proc. 20XX-XX section 11.03 for additional details.

DRAFT AS OF
August 6, 2012

15 For failures involving corrective contributions or distributions, have you detailed and 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. See Rev. Proc. 20XX-XX, section 11.03.
16 For failures involving participant loans that do not comply with section 72(p) requirements, have you included:
• An attachment that contains a detailed description of the failure;
• An attachment that requests income tax relief, and/or a request to report the distribution on Form 1099-R in the year of
correction instead of the year of failure;
• For cases in which income tax relief has been requested, detailed calculations and narrative that detail the correction
proposal and demonstrate compliance with the requirements set forth in section 6.07 of Rev. Procedure 20XX-XX?
17 For operational failures that have resulted in certain excise taxes, have you included an attachment requesting a waiver of
the excise tax under sections 4972, 4973, 4974, or 4979 or additional income tax under section 72(t), as applicable? Where
required, have you included detailed explanations supporting the request? See section 6.09 of Rev. Proc. 20XX-XX for
additional information as to when such waiver requests are applicable.
18 Have you included an attachment that describes the method(s) that will be used to locate and notify former employees or, if
there are no former employees affected by the failure listed in this VCP submission or the correction(s), provided an
affirmative statement to that effect? See Rev. Proc. 20XX-XX section 11.03.
19 If the failure described in this VCP submission includes a failure related to Transferred Assets as defined in section 5.01(7)
of Rev. Proc. 20XX-XX have you included an attachment that describes the related employer transaction, including the date
of the employer transaction and the date the assets were transferred to the plan?
20 If the failures described in this VCP submission include operational failures, have you included a copy of the plan document
(and adoption agreement, if applicable) or applicable provisions of the plan document, that were in effect during the period
of failure?

Form 8950 (8-2012)

Version A, Cycle 2
Fillable Field Font: Times; Size 10 pt; Color: Black;
Fillable Fields need script inserted for Forced upper case. If adding fields, copy script from "exit".

Page 6

Form 8950 (8-2012)

Procedural Requirements Checklist
for Form 8950 (Continued)
21 If the failures described in this VCP submission include non-amender failures other than late interim amendments, have you
included a copy of the plan document in effect prior to any of the amendments used to correct the failure(s)?
22 If the described qualification failures are being corrected by plan amendments or the adoption of a written plan, have you:
• Included copies of the corrective amendments?
• If correcting interim amendment failures or a failure to adopt a written 403(b) plan timely, have you submitted corrective
executed copies that have been executed by the plan sponsor?
• If a restated plan document is being submitted as evidence of correction, have you included an attachment that
identifies the page and section of the document, and the specific plan language that resolves each specified qualification
failure described in the VCP submission?
23 If the subject of this VCP submission is a 403(b) plan, has a written attachment been included that contains the following
items:

INTERNAL USE ONLY

• A statement as to the type of employer (e.g., a tax-exempt organization described in section 501(c)(3)) who is making
the VCP submission.
• A statement indicating that the Plan Sponsor has contacted all other entities involved with the plan and has been
assured of cooperation in implementing the applicable correction, to the extent necessary.

24 If you wish to receive an Acknowledgement letter that we have received your VCP application and submission, have you
included an Appendix D document with your submission? Appendix D is part of Rev. Proc. 20XX-XX.

DRAFT AS OF
August 6, 2012

25 Have you assembled your submission as described in section 11.15, and for those submissions with related determination
letter applications, have you included separate copies of all necessary plan documents and amendments so that each
submission has its own copies? See Rev. Proc. 20XX-XX, section 11.04.
26 If this VCP submission is limited to a minor modification to a previously issued compliance statement as allowed by Rev.
Proc. 20XX-XX, section 10.07(10), have you met the conditions for this type submission?
If "Yes", have you included a letter explaining the modification, a copy of the original issued compliance statement, a copy
of the original VCP submission and, if applicable, any other correspondence relating to the issuance of the original
compliance statement?

Form 8950 (8-2012)