Form (Rev. September 2015) 8950 Application for Voluntary Correction Program (VCP) Under the Employee Plans Compliance Resolution System (EPCRS) Information about Form 8950 and its instructions is at www.irs.gov/form8950. OMB No. 1545-1673 For IRS Use Only Department of the Treasury Internal Revenue Service Review the attached Procedural Requirements Checklist before mailing this VCP submission to the IRS. 1a Name of plan sponsor (employer if single-employer plan) 1b Address of plan sponsor (if a P.O. box, see instructions) 1c City or town 1d State 1e ZIP code 1f Foreign country name 1g Foreign province/county 1h Foreign postal code 1i Employer identification number 1j Telephone number 1k Fax number 1l NAICS Business Code 2a Person to contact if more information is needed. (see instructions) (If a Power of Attorney is attached, check box and do not complete lines 2a through 2g.) Name 2b Address 2c City or town 2d State 2e ZIP code 2f Telephone number 2g Fax number If more space is needed for any line items, attach additional sheets of the same size as this form. Identify each additional sheet with the plan sponsor's name and EIN and identify the corresponding line item. Under penalties of perjury, I declare that I have examined this VCP submission, including Form 8950 and all 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 generally be signed by the owner or an authorized employee of the plan sponsor. For exceptions, see instructions under Who Must Sign. Type or print name Type or print title For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 37769K Form 8950 (Rev. 9-2015) American LegalNet, Inc. www.FormsWorkFlow.com Form 8950 (Rev. 9-2015) Page 2 3 Type of VCP submission (see instructions) Check one: VCP regular submission VCP anonymous submission VCP group submission Non-VCP 457(b) submission (as permitted by Rev. Proc. 2013-12, section 4.09) 4a Name of plan: 4b Enter 3-digit plan number (see instructions) 4c Enter month plan year ends (MM) (see instructions) 5 4d Enter the dollar value of the plan's assets (see instructions) 4e Enter number of participants (see instructions) (Enter only one plan type) Indicate type of plan by entering the corresponding number from the list below: 01-Profit sharing (not 401(k)) 02-401(k) 14-Stock bonus 03-Money purchase 06-Target benefit 04-Defined benefit (not cash balance or other statutory hybrid) 09-Cash balance or other statutory hybrid 05-ESOP 15-KSOP 07-403(b) 08-457(b) 10-Governmental 414(d) defined benefit 20-Governmental 414(d) defined contribution 11-SEP 12-SARSEP 13-SIMPLE IRA 16-Group submission defined contribution 17-Group submission defined benefit 99-Other (see instructions) Form 8950 (Rev. 9-2015) American LegalNet, Inc. www.FormsWorkFlow.com Form 8950 (Rev. 9-2015) Page 3 Yes 6 No Are all qualification failures and correction methods in this VCP submission being resolved by the use of schedules specified on Forms 14568-A through 14568-I? If "Yes," please indicate the specific schedules you are submitting. Form 14568-A, Sch 1 Form 14568-B, Sch 2 Form 14568-C, Sch 3 Form 14568-D, Sch 4 Form 14568-E, Sch 5 Form 14568-F, Sch 6 Form 14568-G, Sch 7 Form 14568-H, Sch 8 Form 14568-I, Sch 9 7a 7b If you are proposing to correct any section 401(a) qualification failure, does the correction include a retroactive plan amendment (see instructions)? If 7a is "Yes," have you concurrently submitted a Form 5300 series, Application for Determination for Employee Benefit Plan (see instructions)? If 7b is "No," attach an explanation as to why such determination letter application was not submitted. 7c If 7a is "Yes," indicate the plan's remedial amendment cycle as determined by Rev. Proc. 2007-44 (or successor) that was in effect as of the date of this VCP submission (see instructions): 8 Has the plan or plan sponsor been party to an abusive tax avoidance transaction (see Rev. Proc. 2013-12, section 4.13(2))? If "Yes," attach an explanation that provides details of the transaction (see instructions). 9 10 11 Does the VCP submission relate to the diversion or misuse of plan assets (see Rev. Proc. 2013-12, section 4.12)? As of the date this VCP submission is mailed to the IRS, is the plan sponsor or the plan under examination, as defined in Rev. Proc. 2013-12, section 5.09? If "Yes," you are ineligible for VCP (see instructions). As of the date this VCP submission is mailed to the IRS, is the plan being considered in an unrelated Form 5300 series determination letter application? If "Yes," include an attachment indicating the date the application was filed with the IRS and the determination letter application case number. 12 Have you previously filed a Form 5300 series determination letter application for this plan with the IRS that was subsequently closed or withdrawn as a result of a failure to respond to a request for additional information? If "Yes," attach an explanation (see instructions). Form 8950 (Rev. 9-2015) American LegalNet, Inc. www.FormsWorkFlow.com Form 8950 (Rev. 9-2015) Page 4 Procedural Requirements Checklist You do not have to use this checklist, but it may help prevent delayed IRS processing caused by an incomplete submission. 1 Is Form 8951, Compliance Fee for Application for Voluntary Correction Program (VCP) Under the Employee Plans Compliance Resolution System (EPCRS), attached to Form 8950? 2 Is the appropriate compliance fee for your submission (and a photocopy of the compliance fee check) attached to Form 8951? 3 If appropriate, is Form 2848, Power of Attorney and Declaration of Representative, and/or Form 8821, Tax Information Authorization, attached? For more information, see Disclosure Request by Taxpayer in the instructions and Rev. Proc. 2015-4 (or its successor). 4 Is the employer identification number (EIN) of the plan sponsor/employer (NOT the trust's EIN, or an individual's SSN) entered on line 1i? See Line 1i in the instructions. 5 Is the application signed and dated? It generally must be signed by an authorized employee or the owner of the plan sponsor. See Who Must Sign in the instructions for situations where the signer may be a different person. 6 If you are submitting Form 14568, Model VCP Compliance Statement, or any model document schedules using Forms 14568-A through 14568-I, have you used the latest official vers