Form 15417-G – 403(b) Plan Elective Deferrals Worksheet 12A

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If you reach for Form 15417-G expecting to test the §402(g) dollar limit or excess deferrals, you reached for the wrong worksheet. Those live on Worksheet 6A. Form 15417-G is Worksheet 12A, the IRS Employee Plans examiner checklist for whether a 403(b) plan's elective deferral provisions comply with the Code, Catalog Number 94035V, revision 4-2023. It is an internal examiner tool; employers, sponsors, participants, and recordkeepers never file or sign it.

The worksheet runs six sections, from Applicability through the EACA provisions, with a Plan Reference column beside Yes, No, and N/A answers. Several rows are shaded cross-references to other worksheets and need no answer. The EACA section gets completed only if the plan actually has EACA provisions, where the 2½-month §4979 distribution window or the extended 6-month window decides how excess contributions are handled.

Key Takeaways

• What it is: Worksheet 12A (Catalog Number 94035V, revision 4-2023) – the IRS Employee Plans examiner checklist for determining whether a 403(b) plan’s elective deferral provisions comply with the Internal Revenue Code.
• Who uses it: IRS Employee Plans examiners during 403(b) plan examinations – not employers, plan sponsors, participants, or any taxpayer.
• Structure: Six sections (I. Applicability, II. Contributions, III. Limits and Catch-Ups, IV. Universal Availability, V. Vesting, VI. Eligible Automatic Contribution Arrangements) with a Plan Reference column plus Yes / No / N/A answer columns.
• Shaded cross-references: Section III (all four items), IV(a), and V(a) are shaded pointers to Worksheet 6A (limits), Worksheet 1A (eligibility), and Worksheet 2B (vesting); no answer is required on shaded rows.
• Section VI trigger: The EACA section is completed only if the plan contains EACA provisions. Partial-EACA plans keep the 2½-month §4979 distribution window; the 6-month extended window applies only when all participants are EACA-covered.
• SOP tip: Stage Worksheets 1A, 2B, 6A, and 15 alongside 12A on day one, and document a plan-reference citation for every unshaded item before answering Yes / No / N/A.

What Form 15417-G Is and When to Use It

Form 15417-G, “403(b) Plan Elective Deferrals – Worksheet 12A – Determination of 403(b) Status,” is the IRS Employee Plans examiner worksheet used during plan examinations to determine whether a 403(b) plan’s elective-deferral provisions comply with the Internal Revenue Code. The form is issued by the Department of the Treasury – Internal Revenue Service, runs two pages, and carries Catalog Number 94035V with a revision date of 4-2023.

Form 15417-G is an internal IRS publication, not a taxpayer return. Employers, plan sponsors, participants, and recordkeepers do not file, sign, or complete it. The form contains examiner Yes / No / N/A determinations, a Plan Reference column for citing the supporting plan-document section, and a “Name of plan” field at the header.

The worksheet applies only to 403(b) plans – not 401(k) plans, IRAs, or 457 plans. The technical principles in the worksheet reflect rules current as of the 4-2023 revision and may be modified by subsequent regulations or guidelines (including SECURE 2.0 layer-ins).

When the Worksheet Is Used

An IRS Employee Plans examiner uses Form 15417-G during a 403(b) plan examination to walk through the plan’s elective-deferral provisions item-by-item. Item I(a) is a skip trigger: if the plan does not offer elective deferrals, the entire worksheet is skipped. If the plan does offer elective deferrals, the examiner proceeds through Sections II through V (plus VI if the plan contains EACA provisions).

Completion Rules

Per the worksheet instructions, all unshaded items must be completed with Yes / No / N/A; shaded rows are cross-references to other worksheets (Worksheet 1A for eligibility, 2B for vesting, 6A for limits, 15 for distributions) and require no answer. A “Yes” generally indicates a favorable conclusion; a “No” indicates a problem exists and must be explained in the space provided on the worksheet.

How to Complete Form 15417-G

Form 15417-G is completed by an IRS Employee Plans examiner during a 403(b) plan examination. The examiner records the plan name at the header, then walks through each unshaded item answering Yes / No / N/A and citing the supporting plan-document section in the Plan Reference column. Shaded items (Section III in full, IV(a), V(a)) are cross-references to other worksheets and require no answer.

Section	Items	Notes
I. Applicability	2 items (a, b)	Skip the entire worksheet if I(a) is No (plan does not offer elective deferrals)
II. Contributions	4 items (a, b, c, e – item d is intentionally omitted)	Covers eligibility, Roth designations, includible-income timing, and separate accounting for pre-tax vs. designated Roth
III. Limits and Catch-Ups	4 shaded cross-references (a–d)	All four route to Worksheet 6A (basic §402(g)(1) limit, age-50 and special 403(b) catch-ups, excess deferrals, definition of compensation) – no Yes / No / N/A answer required
IV. Universal Availability	1 shaded cross-reference (a)	Routes to Worksheet 1A for Treas. Reg. §1.403(b)-5(b) universal availability and effective opportunity
V. Vesting	1 shaded cross-reference (a)	Routes to Worksheet 2B
VI. EACAs	9 items (a–i)	Complete only if the plan contains EACA provisions; covers default percentage, annual notice, 90-day permissible-withdrawal window, fee cap, §402(g) exclusion of permissible withdrawals, match forfeiture, and the 6-month vs. 2½-month §4979 distribution window

The Six Sections of Worksheet 12A

Form 15417-G is organized into six substantive sections (I–VI). Knowing what each section asks – and which items route out to other worksheets – lets an examiner work the form efficiently without re-reading the instructions every time.

Section I – Applicability

Two items (a, b). Item I(a) asks whether the plan offers elective deferrals; if the answer is No, the entire worksheet is skipped. Item I(b) confirms that elective deferrals are properly defined under the plan.

Section II – Contributions

Four items labeled a, b, c, e (item d is intentionally omitted on the form). The section covers eligibility to make elective deferrals (with a cross-reference to Worksheet 1A), the irrevocable Roth designation requirement at the time of the cash-or-deferred election, the includible-income timing rule for designated Roth contributions, and the separate accounting requirement for pre-tax elective deferrals versus designated Roth contributions.

Section III – Limits and Catch-Ups

Four shaded cross-reference items (a–d). All four point to Worksheet 6A: the basic §402(g)(1) limit on elective deferrals, the age-50 and special section 403(b) catch-ups, the treatment of excess deferrals, and the definition of compensation. No Yes / No / N/A answer is required on Section III – the examiner follows the Worksheet 6A cross-reference instead.

Sections IV and V – Universal Availability and Vesting

Each section has a single shaded cross-reference. Section IV(a) routes to Worksheet 1A for the universal availability requirements of Treas. Reg. §1.403(b)-5(b). Section V(a) routes to Worksheet 2B for vesting determinations.

Section VI – EACA Provisions Deep Dive

Section VI of Worksheet 12A is completed only when the plan contains Eligible Automatic Contribution Arrangement (EACA) provisions. If the plan does not provide an EACA, the section is skipped entirely. When it does apply, the examiner walks through nine items (a–i) covering the structural requirements of the EACA.

Covered Employees, Default Percentage, and Notice

Items VI(a)–(c) confirm that the plan provides an EACA, identifies which employees are covered, that the default percentage satisfies the uniformity requirement, and that proper notice is given to covered employees within a reasonable period before each plan year.

Permissible Withdrawals (90-Day Cap)

Items VI(e)–(g) cover EACA permissible withdrawals. The plan must require that elections for permissible withdrawals occur within 90 days; longer windows do not satisfy this item. The plan must specify the correct withdrawal amount, and fees on a permissible withdrawal must be no more than the fees charged for any other cash distribution.

§402(g) Exclusion and Match Forfeiture

Item VI(h) confirms that default elective deferrals distributed pursuant to the EACA permissible withdrawal provision are not counted toward the §402(g) dollar limit, and that matching contributions on the withdrawn default deferral are not allocated (or are forfeited if already allocated).

The 6-Month vs. 2½-Month §4979 Distribution Window

Item VI(i) addresses the timing for distributing excess aggregate contributions to avoid the IRC §4979 10% excise tax. If – and only if – all participants are covered employees under the EACA, the plan may state it has 6 months (rather than the standard 2½ months) after the plan year-end to distribute. Partial-EACA plans stay on the 2½-month deadline.

Answering Items: Yes / No / N/A and the Plan Reference Column

Every unshaded item on Worksheet 12A is answered in one of three columns – Yes, No, or N/A – and the examiner cites the specific section of the plan document supporting that answer in the Plan Reference column.

A “Yes” answer generally indicates that a favorable conclusion is warranted with respect to that item. A “No” answer indicates a problem exists with the plan, and the examiner must use the space provided on the worksheet to explain that “No” answer. “N/A” is appropriate when the underlying provision does not apply (for example, Section VI items on a plan that does not contain an EACA).

Shaded rows are different: they are cross-references to other worksheets (Worksheet 1A for eligibility and universal availability, 2B for vesting, 6A for limits and catch-ups, and Worksheet 15 for distributions). Per the worksheet instructions, shaded rows indicate no answer is required – the examiner follows the referenced worksheet rather than recording Yes / No / N/A on the 12A row itself.

Related Worksheets Referenced by Form 15417-G

Form 15417-G does not stand alone. Section III in full, Section IV(a), and Section V(a) are shaded cross-references that route the examiner out to companion worksheets in the IRS Employee Plans compliance worksheet series. Stage these worksheets alongside 12A from day one.

Worksheet	Topic	Where Referenced on 12A
Worksheet 1A	Eligibility and Participation for 403(b) Plans (universal availability, effective opportunity)	Section II(a) and Section IV(a)
Worksheet 2B	Vesting	Section V(a)
Worksheet 6A	Limits: basic §402(g)(1), age-50 catch-up, special 403(b) catch-up, excess deferrals, definition of compensation	All four items in Section III (a–d)
Worksheet 15	Distribution requirements concerning elective deferrals	Referenced in the worksheet instructions (“See WS 15”)

The most common error on Section III is trying to verify the §402(g) dollar limit (e.g., the annual elective-deferral cap) directly from Worksheet 12A. No dollar amounts appear on 12A – the figures and treatment all live on Worksheet 6A.

Common Mistakes That Slow Things Down

Per the IRS Form 15417-G worksheet (revision 4-2023), the same handful of patterns trip up plan sponsors and Employee Plans reviewers on the first pass through Worksheet 12A.

Practical Checklists You Can Reuse

These checklists are copy-paste ready for plan-compliance SOPs handling Worksheet 12A (Form 15417-G) reviews.

Keep 15417-G Season From Stalling

Worksheet 12A reviews stack up unevenly across the year: Employee Plans examination cycles, plan restatements, and SECURE 2.0 layer-ins all push 403(b) plan sponsors to verify Section VI EACA provisions, Section III limit cross-references, and Section II contribution definitions on tight turnarounds (per the IRS Form 15417-G worksheet, revision 4-2023). Skip one cross-reference to Worksheet 6A or miss the 90-day permissible withdrawal cap, and the entire compliance file slips to the back of the queue.

The fix is to treat Worksheet 12A like any other examination workpaper: a structured pull-list, named ownership for each section, and a separate lane for EACA-only items so they do not bottleneck the Yes / No / N/A pass on Sections I through V.

• Build a Section VI EACA sub-checklist that runs only when the plan contains an EACA, so non-EACA plans clear the worksheet in a single pass.
• Stage Worksheets 1A, 2B, 6A, and 15 alongside 12A on day one – every shaded row points to one of these and a missing pull stalls the review.
• Document a plan-reference column citation for every unshaded item, so the reviewer never has to chase the source plan document twice.
• Calendar the 2 1/2-month and 6-month §4979 distribution windows separately, so partial-EACA plans never inherit the extended window by mistake.
• Track each No answer with a one-line explanation in the same packet, instead of routing back to the preparer for context after the fact.

Accountably staffs Worksheet 12A reviews and the Worksheet 1A / 2B / 6A / 15 cross-references on the same delivery cycle, so the compliance file comes back as one structured packet instead of four. See our taxation services for how the 403(b) compliance lane is staffed.

FAQs

What is Form 15417-G?

Form 15417-G is the IRS Employee Plans examiner worksheet – also known as Worksheet 12A (Catalog Number 94035V, revision 4-2023) – used to determine whether a 403(b) plan’s elective deferral provisions comply with the Internal Revenue Code. It is an internal IRS checklist, not a form filed by employers, plan sponsors, participants, or any taxpayer.

Who uses Form 15417-G?

IRS Employee Plans examiners use Form 15417-G during 403(b) plan examinations. The examiner records Yes, No, or N/A for each unshaded item and cites the supporting plan-document section in the Plan Reference column. Employers, plan sponsors, participants, and recordkeepers do not file or sign the form.

What sections does Form 15417-G contain?

Six sections: I. Applicability, II. Contributions, III. Limits and Catch-Ups, IV. Universal Availability, V. Vesting, and VI. Eligible Automatic Contribution Arrangements (EACAs). Section VI is completed only if the plan contains EACA provisions. All four items in Section III are shaded cross-references to Worksheet 6A.

Does Form 15417-G contain the §402(g) dollar limit?

No. The basic §402(g)(1) limit on elective deferrals, the age-50 catch-up, the special 403(b) catch-up, the treatment of excess deferrals, and the definition of compensation are all evaluated on Worksheet 6A, not on Worksheet 12A. Section III items on Form 15417-G are shaded cross-references to Worksheet 6A and require no Yes / No / N/A answer.

When does the EACA 6-month distribution window apply?

The extended 6-month (rather than 2½-month) deadline to distribute excess aggregate contributions and avoid the IRC §4979 10% excise tax applies only when all participants are EACA-covered employees. Partial-EACA plans remain on the standard 2½-month deadline.