vcfpchecklist

Voluntary Fiduciary Correction Program
Checklist
U.S. Department of Labor
Employee Benefits Security Administration
April 2006

Use this checklist to ensure that you are submitting a complete Voluntary Fiduciary Correction
Program (VFCP) application. The applicant must sign and date the checklist and include it with the
application. Indicate ‘‘Yes’’, ‘‘No’’ or ‘‘N/A’’ next to each item. A ‘‘No’’ answer or the failure to include a
completed checklist will delay review of the application until all required items are received.
Yes

No

N/A

1. Have you reviewed the eligibility, definitions, transaction and
correction, and documentation sections of the VFCP?

Yes

No

N/A

2. Have you included the name, address and telephone number of a
contact person familiar with the contents of the application?

Yes

No

N/A

3. Have you provided the EIN, Plan Number, and address of the plan
sponsor and plan administrator?

Yes

No

N/A

4. Have you provided the date that the most recent Form 5500 was
filed by the plan?

Yes

No

N/A

5. Have you enclosed a signed and dated certification under penalty of
perjury for each applicant and the applicant’s representative, if any?

Yes

No

N/A

6. Have you enclosed relevant portions of the plan document and any
other pertinent documents (such as the adoption agreement, trust
agreement, or insurance contract) with the relevant sections
identified?

Yes

No

N/A

7. If applicable, have you provided written notification to EBSA of any
current investigation or examination of the plan, or of the applicant
or plan sponsor in connection with an act or transaction directly
related to the plan by the PBGC, any state attorney general, or any
state insurance commissioner?

Yes

No

N/A

8. Where applicable, have you enclosed a copy of an appraiser’s
report?

Yes

No

N/A

9. Have you enclosed supporting documentation, including:
 a. A detailed narrative of the Breach, including the date it
occurred;
 b. Documentation that supports the narrative description of
the transaction;
 c. An explanation of how the Breach was corrected, by
whom and when, with supporting documentation;
 d. A list of all persons materially involved in the Breach and
its correction (e.g., fiduciaries, service providers,
borrowers, lenders);
 e. Specific calculations demonstrating how Principal
Amount and Lost Earnings or Restoration of Profits were
computed, or, if the Online Calculator was used, a copy

of the “Print Viewable Results” pages(s) after completing
use of the Online Calculator; and
 f. Proof of payment of Principal Amount and Lost Earnings
or Restoration of Profits; and
 g. If application concerns delinquent employee
contributions or loan repayments, 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 and supporting documentation on which the Plan
Official relied?
Yes

No

N/A

10. If you are an eligible applicant and wish to avail yourself of excise
tax relief under the VFCP Class Exemption:
 a. Have you made proper arrangements to provide within
60 calendar days after submission of this application a
copy of the Class Exemption notice to all interested
persons and to the EBSA regional office to which the
application is filed; or
 b. If you are relying on the exception to the notice
requirement in section IV.C. of the Class Exemption
because the amount of the excise tax otherwise due
would be less than or equal to $100.00, have you
provided to the appropriate EBSA Regional Office a copy
of a completed IRS Form 5330 or other written
documentation containing the information required by
IRS Form 5330 and proof of payment?

Yes

No

N/A

11. In calculating Lost Earnings, have you elected to use:
 a. The Online Calculator; or
 b. A manual calculation performed in accordance with
Section 5(b)?

Yes

No

N/A

12. Where applicable, have you enclosed a description demonstrating
proof of payment to participants and beneficiaries whose current
location is known to the plan and/or applicant, and for individuals
who need to be located, have you described how adequate funds
have been segregated to pay missing individuals and commenced
the process of locating the missing participants individuals using
either the IRS and SSA locator services, or other comparable
means?

Yes

No

N/A

13. For purposes of the three transactions covered under Section 7.1
has the plan implemented measures to ensure that such
transactions do not recur?

Name of Applicant:
Signature of Applicant and Date Signed:
Title/Relationship to the Plan:
Name of Plan, EIN and Plan Number:
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 must complete this form and submit it as part of the application 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 that you have satisfied the requirements of the Program. EBSA estimates that completing and submitting this form will require an average of 2 to 4
minutes. 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.