0423 Form 15417-G (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15417g.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

403(b) Plan

Elective Deferrals¶

Worksheet 12A – Determination of 403(b) Status

Instructions - All items must be completed (except for cross-references, which are shaded to indicate no answer is required). 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.

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

Name of plan

Explain any "No" answers in this section

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IV. Universal Availability	Plan Reference	Yes	No	N/A
a. For universal availability requirements under 1.403(b)-5(b) for elective deferrals and designated Roth contributions, see Worksheet 1A (Eligibility and Participation for 403(b) Plans)
V. Vesting	Plan Reference	Yes	No	N/A
a. For vesting, see Worksheet 2B
VI. Eligible Automatic Contribution Arrangements (EACAs) (Complete if the plan contains EACA provisions)	Plan Reference	Yes	No	N/A
a. Does the plan provide an EACA? If not, skip this section
b. Does the plan identify covered employees under the EACA
c. Does the default percentage satisfy the uniformity requirement
d. Does the plan provide that proper notice will be given to covered employees within a reasonable period before each plan year
e. If applicable, does the plan require that elections for permissible withdrawals be made within 90 days
f. If applicable, does the plan specify the correct amount of a permissible withdrawal
g. Are the fees charged for a permissible withdrawal no more than any other cash distribution
h. (i) Does the plan provide that default elective deferrals distributed pursuant to the EACA provision are not counted towards the dollar limitation on elective deferrals contained in Code § 402(g)? (ii) Does the plan provide matching contributions on permissible withdrawals will not be allocated or if already allocated will be forfeited
i. If the plan provides that all participants are covered employees, then does the plan state that it has until 6 months (rather than 2½ months) after the end of the plan year to distribute excess aggregate contributions and avoid the Code § 4979 10% excise tax

See WS 15 for requirements of distributions concerning elective deferrals

Explain any "No" answers in this section

Form 15417-G (4-2023) Catalog Number 94035V publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Exceptions & meaning →