Form 886A – Fill Out and Use This PDF

Form 886A		Department of the Treasury - Internal Revenue Service	Schedule No. or
		Explanation of Items
			Exhibit
Name of Taxpayer			Year/Period Ended

Please provide the following information:

1)After receiving the 1564-B Letter, did the review of your employment and section 403(b) plan eligibility records confirm a failure to meet the universal availability requirement of section 403(b)(12)(A)(ii) of the Internal Revenue Code?

a)If no, please explain your method of review and your results (include why there was no failure). [After completion of this response, proceed to the Contact Name section below]

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b)If yes, please indicate the employee group(s) and number of eligible employees affected by the failure. For Example: Substitute Teacher – 4 affected employees, Nurse -1 affected employee, Cafeteria Worker – 6 affected employees, Bus Driver – 20 affected employees.

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2) Was a contribution made to the section 403(b) plan to correct the failure?

a)If no, please explain why not.

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b)If yes, please provide the total dollar amount and date of this contribution.

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Form 886-A (1-1994) Catalog Number 20810W Page publish.no.irs.gov Department of the Treasury-INTERNAL REVENUE SERVICE

Form 886A		Department of the Treasury - Internal Revenue Service	Schedule No. or
		Explanation of Items
			Exhibit
Name of Taxpayer			Year/Period Ended

3)Describe the specific process used to correct the failure (include the method used to determine the dollar amount of the contribution and the vesting percentage applied to it).

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Contact Name (please print) ______________________________________________________

Signature of Person Completing this Response _____________________________________

Title ________________________________ Phone Number ____________________________

Form 886-A (1-1994) Catalog Number 20810W Page publish.no.irs.gov Department of the Treasury-INTERNAL REVENUE SERVICE