This application form provides a recommended format for
your Voluntary Fiduciary Correction Program (VFCP) application. Please make sure you
include the required VFCP
Checklist and all supporting documents identified on the
checklist (for example, proof of
payment). Submit your application to the appropriate EBSA field
office.
For full application procedures, consult www.dol.gov/ebsa.
List separately
Applicant Name
Address
Applicant Name
Address
Applicant Name
Address
Transactions Corrected Check which transactions listed in the VFCP you have
corrected:
Delinquent Participant Contributions and Participant Loan Repayments
to Pension Plans
Delinquent Participant Contributions to Insured Welfare Plans
Delinquent Participant Contributions to Welfare Plan Trusts
Loan at Fair Market Interest Rate to a Party in Interest
Loan at Below-Market Interest Rate to a Party in Interest
Loan at Below-Market Interest Rate to a Non-Party in Interest
Loan at Below-Market Interest Rate Due to Delay in Perfecting Plan’s
Security Interest
Loans Failing to Comply with Plan Provisions for Amount, Duration or
Level Amortization
Default Loans
Purchase of an Asset by a Plan from a Party in Interest
Sale of an Asset by a Plan to a Party in Interest
Sale and Leaseback of Real Property to Employer
Purchase of Asset by a Plan from a Non-Party in Interest at More
Than Fair Market Value
Sale of an Asset by a Plan to a Non-Party in Interest at Less Than
Fair Market Value
Holding of an Illiquid Asset Previously Purchased by a Plan
Payment of Benefits Without Properly Valuing Plan Assets on Which
Payment is Based
Duplicative, Excessive, or Unnecessary Compensation Paid by a Plan
Expenses Improperly Paid by a Plan
Payment of Dual Compensation to a Plan Fiduciary
Correction
Amount
Principal
Amount: $
Date Paid
Lost
Earnings/Restoration of Profit: $
Date Paid
Narrative And Calculations
1. List
all persons materially involved in the Breach and its correction
(e.g., fiduciaries, service providers):
2. Explain the Breach, including the
date(s) it occurred (attach separate sheets if necessary):
3. Explain how the Breach was
corrected, by whom, and when (attach separate sheets if necessary):
4. For correction of Delinquent
Remittance of Participant Funds, provide a statement from a Plan
Official identifying the earliest date on which participant
contributions/loan repayments reasonably could have been segregated
from the employer’s general assets (attach supporting
documentation on which Plan Official relied):
Number of days used to determine
the date on which participant contributions/loan repayments withheld
from employees’ pay could reasonably have been segregated from the
employer’s general assets:
Description of how this was
determined:
5. For correction of Delinquent
Remittance of Participant Funds, provide a narrative describing the
applicant's contribution and/or repayment remittance practices
before and after the period of unpaid or late contributions and/or
repayments: (attach separate sheets if necessary)
6. Specific calculations
demonstrating how Principal Amount and Lost Earnings or Restoration
of Profits was calculated: (if
the Online Calculator was used, you only need to indicate this and
attach a copy of the “Printable Results” page, attach separate sheets if
necessary)
Online Calculator (“Printable Results” page attached)
Manual calculation (see attached calculations)
Supplemental Information
Plan Sponsor
Name:
EIN:
Address:
Plan Name:
Plan Number:
Plan
Administrator Name:
EIN:
Address:
Name of
Authorized Representative: (submit written authorization signed by
the Plan Official)
Address:
Telephone:
Name of
Contact Person:
Address:
Telephone:
Date of Most
Recent Annual Report Form 5500 Filing:
For Plan Year
Ending:
Is
Applicant Seeking Relief Under PTE 2002-51? PTE 2002-51 provides an
exemption from the payment of excise taxes to the Internal Revenue
Service for engaging in certain prohibited transactions. For more
information on PTE 2002-51, see VFCP
Class Exemption FAQs. If the transaction in this application is not covered by PTE
2002-51, you may want to contact your accountant or ERISA advisor to
determine if the excise tax is applicable in your transaction.
Please note that if you take advantage of PTE 2002-51, you do not
need to submit any information or documents to the IRS.
Yes - Either:
Submit a copy of the notice
to interested parties within 60 calendar days of this
application and indicate date of the notice if not on the
notice itself;
or
If you are relying on the
exception to the notice to interested parties requirement
contained in section IV.C. of PTE 2002-51 covering
delinquent participant contributions and participant loan
repayments to pension plans, you may pay the amount of the
excise tax otherwise due directly to the Plan if the amount
is less than or equal to $100. If the amount of the excise
tax is less than or equal to $100 and is paid to the Plan,
you do not need to provide a notice to interested parties.
However, you must provide a copy of a completed IRS Form
5330 or other written documentation showing the calculation
of the excise tax amount and proof of payment of this amount
to the Plan with your VFCP submission if you elect to pay
the excise tax amount (again only an option if less than or
equal to $100) to the Plan.
No
I will pay any applicable
excise tax to the IRS
I have filed a Form 5330 and
paid excise tax
This transaction is not
covered by Section 4975 of the Internal Revenue Code
Proof of Payment
Signed, dated receipt from the
recipient of funds transferred to the plan (such as a
financial institution)
Canceled check
Executed wire transfer
Bank statements for the plan's
account
Other:
Disclosure of a current investigation
or examination of the plan by an agency, to comply with Section
3(b)(3)(v):
PBGC
Any state attorney general
State:
Any state insurance
commissioner
State:
Contact person for the agency
identified:
In order to help us improve our
service, please indicate how you learned about the VFCP:
Authorization Of Preparer I have authorized (name of authorized
representative) to represent me concerning this VFCP application.
Name of Plan
Official
Signature of
Plan Official
Penalty of Perjury Statement - The following
statement must be signed and dated by a plan fiduciary with knowledge of the
transaction that is the subject of the application and by the authorized
representative, if any. Each plan official applying under the VFCP must also
sign and date the statement, which must accompany any subsequent additions
to the application.
Under penalties of perjury I certify that I am not
under investigation (as defined in VFCP Section 3(b)(3)) and that I have
reviewed this application, including all supporting documentation, and to
the best of my knowledge and belief the contents are true, correct, and
complete.
Name and Title
Signature
Date
Name and Title
Signature
Date
This application form provides a recommended format for
your Voluntary Fiduciary Correction Program (VFCP) application. Please make sure you
include the required VFCP
Checklist and all supporting documents identified on the
checklist (for example, proof of
payment). Submit your application to the appropriate EBSA field
office.
For full application procedures, consult www.dol.gov/ebsa.
Paperwork Reduction Act Notice
The information
identified on this form is required for a valid application for the
Voluntary Fiduciary Correction Program of the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA). You are not required to
use this form; however, you must supply the information identified in order
to receive the relief offered under the Program with respect to a breach of
fiduciary responsibility under Part 4 of Title I of ERISA. EBSA will use
this information to determine whether you have satisfied the requirements of
the Program. EBSA estimates that assembling and submitting this information
will require an average of 6 to 8 hours. This collection of information is
currently approved under OMB Control Number 1210-0118. You are not required
to respond to a collection of information unless it displays a currently
valid OMB Control Number.