Department of the Treasury - Internal Revenue Service Form 14568-G (August 2016) Model VCP Compliance Statement - Schedule 7: Failure to Distribute Elective Deferrals in Excess of the 402(g) Limit 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 plan identified above did not comply with the requirements of section 402(g) of the Internal Revenue Code (Code) when participants made deferrals to the plan that exceed specified dollar limits and the excess deferrals were not returned by the plan in a timely manner or were less than what was required. When completing this table, affected plan participants should be counted separately under each year that a return of excess deferrals were not made and not just in the first year of the failure. Calendar Years (Year of Deferral) Number of Participants Affected Amount of Excess Deferrals Distributed (Excluding Earnings) Section II - Description of the Proposed Method of Correction The plan will distribute the excess deferral to the affected plan participant(s) and report the amount as taxable in the year of deferral and in the year distributed. If the plan is a Code section 403(b) plan, the plan sponsor will ensure that the appropriate insurance company or financial institution distributes the excess deferrals to the affected plan participant(s) from the applicable 403(b) annuity contracts or custodial accounts and report the amount as taxable in the year of deferral and in the year distributed. In accordance with Income Tax Regulations � 1.402(g)-1(e)(1)(ii), a distribution to a highly compensated employee is included in the Average Deferral Percentage (ADP) test; however, a distribution to a nonhighly compensated employee is not included in the ADP test. This does not apply to Code section 403(b) plans. For any distributions attributable to elective deferrals designated as Roth Contributions, all distributions will be reported as taxable in the year distributed. Designated Roth contributions will have already been included in income in the year of deferral. The excess deferral to be distributed will also be adjusted for earnings. Earnings will be determined from the end of the year in which the failure occurred through the year of correction. Earnings will be included in the distribution amount that is to be reported as taxable in the year of distribution. Earnings are determined as follows: (Attach additional pages as needed. Label the attachment "Section II of Form 14568-G, Description of the Proposed Method of Correction-Earnings" and include the plan name, Applicant's EIN and plan number at the top of each page): 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. Section IV - Enclosures In addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the Plan Sponsor encloses the following with this submission: 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 correction method proposed) Catalog Number 66151C www.irs.gov For Paperwork Reduction Act information see current EPCRS Revenue Procedure. American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-G (Rev. 8-2016)