0423 Form 15417-I (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15417i.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

403(b) Plan

403(b)(9) Retirement Income Accounts¶

Worksheet 16 – 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 A 403(b)(9) RETIREMENT INCOME ACCOUNT PLAN, USE THIS WORKSHEET FIRST. This worksheet also notes special rules that apply to 403(b)(9)s in regard to requirements on other worksheets.

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 Retirement Income Account a defined contribution program
b. Does the plan specifically state that it is intended to constitute a retirement income account under section 403(b)(9)

Explain any "No" answers in this section

II. Employer Eligibility to Sponsor/Employee Eligibility to Participate	Plan Reference	Yes	No	N/A
a. Is the adopting employer a church-related organization as described in section 1.403(b)-2(b)(6)
i. A church, a convention or association of churches, or an elementary or secondary school of such (see section 3121(w)(3)(A))
ii. A church retirement/welfare board if controlled or associated with a church (see section 414(e)(3)(A))
iii. A qualified church-controlled organization (see section 3121(w)(3)(B)), or
iv. A self-employed minister or chaplain (see section 414(e)(5)(A)), but solely with respect to a retirement income account established for that minister/chaplain
b. Is eligibility under the plan limited to employees (as defined in section 1.403(b)-2(b)(9)) of a church-related organization (including a Non-QCCO) and their beneficiaries (including self-employed ministers and chaplains)

Explain any "No" answers in this section

III. Requirements to be a 403(b)(9) Retirement Income Account	Plan Reference	Yes	No	N/A
a. Does the plan require separate accounting for the retirement income account’s interest in the underlying assets of the plan
b. Does the plan require that the investment performance of the account is based on gains and losses of those underlying assets

Page 2

Explain any "No" answers in this section

Form 15417-I (4-2023) Catalog Number 94037R publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Page 3

Explain any "No" answers in this section

Form 15417-I (4-2023) Catalog Number 94037R publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Exceptions & meaning →