Form 14568-D (August 2016) Department of the Treasury - Internal Revenue Service Model VCP Compliance Statement - Schedule 4 SIMPLE IRAs OMB Number 1545-1673 Include the plan name, Applicant's EIN, and plan number information on each page of the compliance statement, including attachments Plan name EIN Plan number Section I - Identification of Failure(s) and Proposed Method(s) of Correction The following failure(s) occurred with respect to the SIMPLE IRA Plan identified above: (Check failure(s) that apply. Within each failure, check applicable boxes, and provide the information requested.) A. Employer Eligibility Failure The plan was adopted by a plan sponsor who was (or subsequently became) ineligible to sponsor a SIMPLE IRA Plan under the requirements of section 408(p) of the Internal Revenue Code (Code) because the plan sponsor (and, if applicable, its related controlled group or affiliated service group employers) had more than 100 employees (including leased employees, if applicable) who earned $5,000 or more in compensation during the following plan year(s): The plan was adopted by a plan sponsor who was not eligible to sponsor a SIMPLE IRA Plan under the requirements of Code section 408(p) because the plan sponsor established or maintained a another tax favored retirement plan under Code sections 401(a), 403(b), and 408(k)with respect to which contributions were made (or under which benefits were accrued) during any plan year of the SIMPLE IRA Plan. The failure occurred during the following plan year(s): Description of the Proposed Method of Correction: All contributions to the plan ceased as of (insert a date no later than the date this VCP submission is filed with the Service). The plan sponsor will not permit any new employer or salary reduction contributions to be made to the plan. B. Failure to Make Required Employer Contributions The plan sponsor failed to make employer contributions on behalf of eligible employees as required under the terms of the plan. The failure occurred on account of the erroneous exclusion of eligible employees The failure occurred due to errors in the determination of compensation for eligible employees Other (describe): The failure occurred for the following plan years: For the applicable plan years, the provisions of the plan document required the plan sponsor to make employer contributions based on the following formula: 2% nonelective contribution on behalf of each eligible employee who earned at least $5,000 in compensation for the year. Matching contribution on behalf of each eligible employee equal to deferrals up to 3% of compensation. Grace period applied. The plan provided for a matching contribution on behalf of each eligible employee equal to % of compensation. deferrals up to (Note: If the failure occurred for multiple plan years and different employer contribution criteria applied during those years, check the applicable box, and indicate the plan years for which the formula applied.) Catalog Number 66148F www.irs.gov For Paperwork Reduction Act information see current EPCRS Revenue Procedure. American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-D (Rev. 8-2016) Page 2 Plan name EIN Plan number Description of the Proposed Method of Correction: The plan sponsor has contributed (or will contribute) additional amounts to the plan on behalf of each affected employee. For each affected employee, the corrective contribution will be determined by calculating the contribution the employee would have been entitled to receive under the terms of the plan and subtracting any contributions already made on behalf of the employee for the plan year. The corrective contribution made on behalf of an affected employee will be adjusted for Earnings. Earnings will be calculated from the last day of the plan year for which the failure occurred through the date of the corrective contribution. The corrective contribution (adjusted for Earnings) will be made to each affected employee's SIMPLE IRA account. If an affected employee does not have a SIMPLE IRA account, an account will be established for that employee. If the plan did not provide eligible employees with the opportunity to make elective deferrals and the plan provides for matching contributions, the corrective matching contribution will be based on the assumption that the eligible employee would have made an elective deferral equal to 3% of compensation. The total corrective contribution (before adjusting for Earnings) for each plan year is: Year Corrective Contribution The Earnings calculation for an affected employee will be based on one of the following method(s) (check one): Actual investment results of the affected employee's SIMPLE IRA account. The interest rate incorporated in the Department of Labor's Voluntary Fiduciary Correction Program Online Calculator ("VFCP Online Calculator") (http://www.dol.gov/ebsa/calculator/main.html), since the actual Earnings of the affected employee's IRA account cannot be ascertained. Actual investment results for years in which data for the affected employee is available, and the rate incorporated in the VFCP Online Calculator for years in which the actual investment results of the affected employee's IRA account cannot be ascertained. The VFCP Online Calculator was or will be used for the following year(s): Former employees affected by the failure (check one): There are no former employees affected by the failure. Affected former employees (or if deceased, their estate or known beneficiary) will be contacted, and corrective contributions will be made to their SIMPLE IRA accounts. To the extent that an affected former employee or beneficiary cannot be located following a mailing to the last known address, the plan sponsor will take the actions specified below to locate that employee or beneficiary: After such actions are taken, if an affected employee or beneficiary is not found but is subsequently located on a later date, the plan sponsor will make corrective contributions to the affected SIMPLE IRA account at that time. Catalog Number 66148F www.irs.gov American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-D (Rev. 8-2016) Page 3 Plan name EIN Plan number C. Failure to Provide Eligible Employees with the Opportunity to Make Elective Deferrals. The plan sponsor did not provide employee(s) who satisfied the applicable eligibility requirements with the opportunity to make elective deferrals to the SIMPLE IRA plan. The failure occurred for the f