0423 Form 15417-C (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15417c.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

403(b) Plan

Coverage and Nondiscrimination Requirements for Employer Contributions¶

(Other than Matching Contributions)¶

Worksheet 5B – Determination of 403(b) Status

Instructions - All items must be completed. A “Yes” answer generally indicates a favorable conclusion is warranted, while a “No” answer indicates a problem exists. Use the space on the worksheet to explain any “No” answer. If the plan is not required to address a particular item, the question related to that item should be answered “N/A”.

The technical principles in this worksheet may be changed by future regulations or guidelines

Name of plan

I. Applicability	Plan Reference	Yes	No	N/A
a. Is the plan or employer described in (i) or (ii) below
i. Is the plan a governmental plan under 414(d) that is maintained by a State or local government or political subdivision thereof (or agency or instrumentality)? If “Yes”, skip the rest of this worksheet
ii. Is the employer maintaining the plan a church as defined under 3121(w)(3)(A) or a qualified church-controlled organization (QCCO) as defined under 3121(w)(3)(B)? If “Yes”, skip the rest of this worksheet Note: If the employer is a non-QCCO you should continue this worksheet.
b. Is the plan sponsor not in category I(a)(i) or (ii) above and does the plan provide employer contributions other than matching contributions? If “Yes”, continue with this worksheet

Explain any "No" answers in this section

II. Coverage	Plan Reference	Yes	No	N/A
a. With respect to contributions other than elective deferrals, does the plan include a fail-safe provision for correction of failures to satisfy the coverage requirement of 410(b)
i. Does the fail-safe language state exactly how the testing will be done and how the correction will be implemented, with no discretion for the employer in the implementation of the correction
ii. Does the fail-safe language provide that participants’ rights are fixed as of the last day of the relevant plan year and that no other part of the plan may override these rights or take them away Note: fail-safe language is optional. If there is no fail-safe language, answer “N/A”. If the fail-safe language is inadequate, answer “No”.

Explain any "No" answers in this section

Form 15417-C (4-2023) Catalog Number 94031D publish.no.irs.gov Department of the Treasury - Internal Revenue Service

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Explain any "No" answers in this section

Form 15417-C (4-2023) Catalog Number 94031D publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Page 3

Explain any "No" answers in this section

Form 15417-C (4-2023) Catalog Number 94031D publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Exceptions & meaning →