Department of the Treasury - Internal Revenue Service Form 14568-F (August 2016) Model VCP Compliance Statement - Schedule 6 Employer Eligibility Failure (401(k) and 403(b) Plans only) OMB Number 1545-1673 Include the plan name, Applicant's EIN, and plan number information on each page of the compliance statement. Plan name EIN Plan number Section I - Identification of Failure The following failure to comply with Internal Revenue Code (Code) occurred with respect to the plan identified above (check failure that applies) Section 403(b) Plans The plan was intended to satisfy the requirements of Code section 403(b) but was adopted by a plan sponsor that was not a tax-exempt organization described in Code section 501(c)(3) or a public educational organization described in Code section 170(b)(1)(A)(ii). The type of organization sponsoring the Plan during the period of the failure was: The failure occurred during the following plan year(s): Section 401(k) Plans The plan was intended to include a qualified cash or deferred arrangement and satisfy the requirements of Code sections 401(a) and 401(k) but was adopted by an employer that failed to meet the eligibility requirements to establish a § 401(k) Plan. Describe why the plan sponsor was ineligible to maintain the Code section 401(k) Plan: Section II - Description of Proposed Method of Correction Section 403(b) Plans 1. All contributions under the plan ceased as of . (Insert date beginning no later than the date the VCP submission was filed with the Service.) 2. No new employee or employer contributions will be permitted in the future. 3. The assets in the plan will remain in the trust, annuity contract, or custodial account and will be distributed no earlier than the occurrence of one of the permitted events under Code section 403(b)(7) or Code section 403(b)(11). Section 401(k) Plans . 1. All contributions under the plan ceased as of (Insert date beginning no later than the date the VCP submission was filed with the Service.) 2. No new employee or employer contributions will be permitted in the future. 3. The assets in the plan will remain in the trust, annuity contract, or custodial account and will be distributed no earlier than the occurrence of one of the permitted events under Code section 401(k). Section III - 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. Catalog Number 66150R www.irs.gov For Paperwork Reduction Act information see current EPCRS Revenue Procedure. American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-F (Rev. 8-2016)