Department of the Treasury - Internal Revenue Service Form 14568-I (August 2016) Model VCP Compliance Statement - Schedule 9: Limited Safe Harbor Correction by Plan Amendment 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(s) and Proposed Method(s) of Correction The following failure(s) to comply with the Internal Revenue Code (Code) occurred with respect to the plan identified above (check failure(s) that apply) A. Code section 401(a)(17) Failure in a Defined Contribution Plan (check as applicable) Contributions Forfeitures were allocated on the basis of compensation in excess of the limit under Code section 401(a)(17) as provided below: Enter the plan years in which the failure occurred, the amount of the allocations in excess of Code section 401(a)(17) made for each plan year (adjust for earnings), and the number of participants affected by the failure for each plan year: Amounts Allocated in Excess of Plan Year Number of Participants Affected Code section 401(a)(17) Description of Proposed Method of Correction: An additional amount has been (or will be) contributed to the plan on behalf of each of the employees who received an allocation for the year of the failure (excluding each employee for whom there was a Code section 401(a)(17) failure). The amount contributed for an employee is equal to the employee's plan compensation for the year of the failure multiplied by a fraction, the numerator of which is the improperly allocated amount made on behalf of the employee with the largest improperly allocated amount, and the denominator of which is the limit under Code section 401(a)(17) applicable to the year of the failure. In addition, the plan will be retroactively amended by the plan sponsor to reflect the increased contribution and allocation percentages for the plan's participants. Enter the plan years in which the failure occurred, the fraction used to determine the additional amount allocated to employees other than those for whom there was a Code section 401(a)(17) failure, and the total required contribution (before adjusting for Earnings) for each plan year in which the failure occurred: Fraction Used to Determine the Total Required Contribution Plan Year Additional Amount Allocated (Before Adjusting for Earnings) Catalog Number 66156F www.irs.gov For Paperwork Reduction Act information see current EPCRS Revenue Procedure. American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-I (Rev. 8-2016) Page 2 Plan name EIN Plan number The resulting additional amount will be adjusted for earnings from the end of the plan year in which the failure occurred through the date of the corrective contribution. The method for determining the earnings adjustment is as follows (Attach additional pages as needed. Label the attachment "Section IA of Form 14568-I, 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): 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 contributions will be made to the plan on their behalf. 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 on behalf of the affected employee at that time. B. Hardship Distribution Failure Hardship distributions were made to participants under the plan even though the written terms of the plan did not provide for any hardship distributions. All plan participants were entitled to request hardship distributions, and all requests were evaluated in accordance with uniform eligibility standards, as described below: Catalog Number 66156F www.irs.gov American LegalNet, Inc. www.FormsWorkFlow.com Form 14568-I (Rev. 8-2016) Page 3 Plan name EIN Plan number Enter the plan years in which the failure occurred, the number of hardship distributions made for each plan year, and the number and amount of distributions made to highly compensated employees (HCEs) and nonhighly compensated employees (NHCEs) respectively, affected by the failure for each plan year. Number of Hardship Number of Hardship Number of Hardship Distributions Made Amount of Amount of Plan Year Distributions Made Distributions Made During the Plan Distributions Distributions to NHCEs to HCEs Year Description of the Proposed Method of Correction: The failure was (or will be) corrected by having the plan sponsor retroactively amending the plan to provide for the hardship distributions that were made available. The effective date of the corrective amendment is: C. Plan Loan Failure Plan loans were made to participants under the plan even though the written terms of the plan did not provide for any participant loans. All plan participants were entitled to request plan loans under uniform standards of eligibility, and all plan loans made satisfied the requirements of Code section 72(p). Enter the plan years in which the failure occurred, the number of participant plan loans made for each plan year, and the number and amount of plan loans made to highly compensated employees (HCEs) and nonhighly compensated employees (NHCEs) respectively, affected by the failure for each plan year. Number of Plan Number of Plan Number of Plan Amount of Plan Amount of Loans Made During Loans Made to Loans Made to Plan Year Loans Plan Loans the Plan Year NHCEs HCEs . Description of the Proposed Method of Correction: The failure was (or will be) corrected by having the plan sponsor retroactively amending the plan to provide for the plan loans that were made available. The effective date of the corrective amendment is: D. Early Inclusion of Otherwise Eligible Employee Failure Employees: (check applicable boxes) . Who had not satisfied the plan's minimum age or service requirements were treated as eligible participants on a date prior to their being eligible under the plan and were entitled to the same benefits under the plan to which they would have been entitled had