1117 Form 8950 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8950.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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Review the attached Procedural Requirements Checklist before mailing this VCP submission to the IRS.

1a Name of plan sponsor (employer if single-employer plan)

Name

an officer with legal authority to bind a corporation, partnership, or organization. For exceptions, see instructions under Who Must Sign .

Type or print name Type or print title

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 37769K Form 8950 (Rev. 11-2017)

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3 Type of VCP submission (see instructions) Check one:

02-401(k)

05-ESOP

15-KSOP

07-403(b)

08-457(b)

10-Governmental 414(d) defined benefit

20-Governmental 414(d) defined contribution

Form 8950 (Rev. 11-2017)

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Yes No

6 Are all qualification failures and correction methods in this VCP submission being resolved by the use of

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Procedural Requirements Checklist

completed, and you must include the enclosure items listed on each applicable form with your VCP submission. The Form 14568 series may be used as a Model VCP Submission Compliance Statement. Forms 14568-A through 14568-I can be used to resolve certain qualification failures. If you combine the model document schedules with the Form 14568, you must specify in each section of Form 14568 the specific model schedules that are being submitted in that section.

Form 8950 (Rev. 11-2017)

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Procedural Requirements Checklist ( Continued )

including the date of the employer transaction and the date the assets were transferred to the plan? See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.

20 For operational failures, have you included a copy of the plan document (and adoption agreement, if applicable) or applicable provisions of the plan document, that were in effect during the period of failure? See the current EPCRS revenue procedure in effect at the time the submission is made to the IRS.

Form 8950 (Rev. 11-2017)

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Procedural Requirements Checklist ( Continued )

Form 8950 (Rev. 11-2017)