Revised VFCP Model Application Form

Employee Benefits Security Administration

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Revised Voluntary Fiduciary Correction Program
Model Application Form

U.S. Department of Labor
Employee Benefits Security Administration
April 2005

This application form provides a recommended format for your VFCP application. For full application procedures, consult www.dol.gov/ebsa/.

List separately:

Applicant Name	Address
Applicant Name	Address
Applicant Name	Address

List Transaction(s) Corrected

Check which transaction(s) 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
	Participant Loan Amount in Excess of Plan Limitations
	Participant Loan Duration in Excess of Plan Limitations
	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 Other Than Fair Market Value
	Sale of an Asset by a Plan to a Non-Party in Interest at Other 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
	Payment of Dual Compensation to a Plan Fiduciary

Correction Amount

Principal Amount	Date Paid
Lost Earnings/Restoration of Profit	Date Paid

Narrative And Calculations

List all persons materially involved in the Breach and its correction (e.g., fiduciaries, service providers):

Explain the Breach, including the date(s) it occurred (attach separate sheets if necessary):

Explain how the Breach was corrected, by whom, and when (attach separate sheets if necessary):

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):

List specific calculations demonstrating how Principal Amount and Lost Earnings or Restoration of Profits was calculated (attach separate sheets if necessary):

Supplemental Information

Plan Sponsor Name:	EIN:		Address:
Plan Name:		Plan Number:
Plan Administrator Name:	EIN:		Address:
Name of Authorized Representative:	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 the VFCP Class Exemption? Yes No

Authorization Of Preparer

I have authorized (insert 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

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.

Attach supporting documentation here.