Catalog Number 66153Ywww.irs.govForm 14568-H (Rev. 6-2018)For Paperwork Reduction Act information see current EPCRS Revenue Procedure. Form 14568-H(June 2018)Department of the Treasury - Internal Revenue Service Model VCP Compliance Statement - Schedule 8: Failure to Pay Required Minimum Distributions Timely OMB Number 1545-1673 Include the plan name, Applicant222s EIN and plan number on each page of the submission. Plan name EIN Plan number Section I - Identification of Failure (DO NOT USE THIS FORM IF PLAN BENEFITS DID NOT COMMENCE IN A TIMELY MANNER, AT THE PLAN222S NORMAL RETIREMENT AGE OR UPON THE PARTICIPANT222S DEATH. IF YOU CANNOT USE THIS FORM, ATTACH A WRITTEN NARRATIVE TO FORM 14568 AND PROVIDE THE NECESSARY INFORMATION REQUESTED BY THAT FORM.)The plan identified above did not comply with the requirements of Section 401(a)(9) of the Internal Revenue Code (IRC) as required minimum distributions (RMD) were not paid 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 an RMD was not made and not just in the first year of the failure. Calendar Years Number of Participants Affected Total Amount of Missed Required Minimum Distributions (Do Not Include Earnings) Section II - Description of the Proposed Method of Correction Defined contribution plan only - The plan will distribute the required minimum distributions (adjusted for earnings from the date of the failure to the date of distribution) to affected participants. For each affected participant, the required minimum distribution amount for each year in which the failure occurred will be determined by dividing the adjusted account balance on the applicable valuation date by the applicable distribution period. For this purpose, adjusted account balance means the actual account balance, determined in accordance with Section 1.401(a)(9)-5 Q&A-3 of the Income Tax Regulations, reduced by the amount of the total missed minimum distributions for prior years. Earnings will be determined as follows Defined benefit plan only - The plan will distribute the required minimum distributions plus an additional payment representing the loss of use of such amounts. (Note the additional payment is determined in accordance with the plan222s written terms for actuarial equivalence). The additional payment is determined as follows American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Catalog Number 66153Ywww.irs.govForm 14568-H (Rev. 6-2018) Plan name Plan number EIN Defined benefit plan only 226 At the time of the proposed correction is the plan subject to any restriction on lump sum payments under IRC Section 436(d)? Include a copy of the plan222s most current actuarial certification of the plan222s Adjusted Funded Target Attainment Percentage (AFTAP) if 223No224 is checked. YesNo If "Yes", the plan sponsor will contribute to the plan, at the time of correction, an amount equal to the corrective distribution mentioned in this compliance statement as discussed in the current EPCRS revenue procedure. Section III - Request for Relief A. The Applicant requests relief with regard to excise taxes under IRC Section 4974YesNo At least one affected participant is either an owner-employee (see IRC Section 401(c)(3)) or, if the plan sponsor is a corporation, a 10 percent owner of such corporation.If 223Yes,224 the Applicant submits the following explanation for its request for relief from the Section 4974 excise tax Section IV - Change in Administrative ProceduresInclude 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 V - EnclosuresIn addition to the applicable items listed on the Procedural Requirements Checklist for Form 8950, the plan sponsor encloses the following with this submission:225Specific calculations for each affected employee or a representative sample of affected employees.225The sample calculations must be sufficient to demonstrate each aspect of the proposed correction method.225For defined benefit plans, the calculations must illustrate the interest rate used to represent the loss of the use of themissed required minimum distributions.225For defined contribution plans, the calculations must show how earnings were determined and their impact on thecalculation of the corrective distributions.225For defined benefit plans, a copy of the plan222s most current AFTAP certification if the Applicant has indicated that theplan is not under IRC 436(d) restrictions. American LegalNet, Inc. www.FormsWorkFlow.com