15417

403(b) Plan Eligibility and Participation Worksheet 1A – Determination of 403(b) Status

Agency
IRS
Revision
4-2023
Fillable fields
81
Pages
2
Official source
IRS form page
Checked
October 21, 2026
Fill 15417 online
Page 1 of form 15417

Form 15417: 403(b) Plan Eligibility and Participation Worksheet 1A

Form 15417 (4-2023) is a two-page IRS worksheet titled 403(b) Plan Eligibility and Participation, Worksheet 1A, Determination of 403(b) Status. A line at the top of each page reads "For applications submitted to conform to the 2021 RA List." It goes through a named 403(b) plan item by item, with a Plan Reference column and Yes, No and N/A boxes on every item.

The instructions printed at the top say "All items must be completed." They explain that a "Yes" answer generally indicates a favorable conclusion is warranted, while a "No" answer indicates a problem exists, and each section has space to explain any "No" answer. The form also notes that its technical principles may be changed by future regulations or guidelines.

The worksheet does not say who fills it out or where it goes, and no separate instructions are linked to it. You can fill it out free in your browser on this page and download the result without an account.

What's on Form 15417

Header and directions

The 2021 RA List line, the worksheet title, the instructions paragraph and a Name of plan line. Every item row has Plan Reference, Yes, No and N/A columns.

I. 403(b) Employer Eligibility Requirements

Whether the employer is an eligible employer under section 1.403(b)-2(b)(8), and whether employees of related employers are taken into account for the exclusion under section 1.403(b)-3.

II. Eligibility of Employees

Whether contributions are made only for common law employees providing service for the employer, and how the plan defines a participant.

III. Universal Availability Requirement for Elective Contributions

Items a to f: church or QCCO sponsors, the all-employees rule, allowed exclusions, the less than 20 hours per week exclusion, the Once-In-Always-In Rule and the effective opportunity requirement.

IV. Participation Requirements for Non-Elective Contributions

Whether the plan has contributions other than elective deferrals, and whether it has a fail-safe provision for correcting failures to satisfy the coverage requirement of Section 410(b).

How to fill out Form 15417

  1. 1

    Name of plan

    Enter the name of the plan on the line at the top of page 1.

  2. 2

    Sections I and II

    For each item, fill in the Plan Reference column and check Yes, No or N/A. The directions say all items must be completed.

  3. 3

    Section III

    Answer III(a) first: a church or QCCO sponsor skips the rest of the worksheet. If the plan does not offer elective deferrals, the form says to skip this section (and WS 11a, Elective Deferrals for 403(b)).

  4. 4

    Part-time employees

    Items III(d) and III(e) cover employees who normally work less than 20 hours per week and the Once-In-Always-In Rule under section 1.403(b)-5(b)(4)(iii).

  5. 5

    Section IV

    Skip it for a church, QCCO or governmental entity sponsor. Otherwise answer IV(b), and if the plan has a fail-safe provision, answer IV(c)(i) and (ii).

  6. 6

    Explain No answers

    Use the space at the end of each section to explain any "No" answer, since the form says a "No" answer indicates a problem exists.

Work through the sections in order. Each section ends with a space headed Explain any "No" answers in this section.

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Where it goes and related worksheets

No address or deadline

The worksheet prints no mailing address, filing method, recipient or deadline, and it has no signature line.

No separate instructions

The IRS listing gives only the PDF. The worksheet's directions are the short paragraph at the top of page 1 and the notes printed under some items.

Date in the OIAI note

The note under item III(e) says that if the plan qualified for operational relief under Notice 2018-95 for failing to comply with the OIAI rule, corrective plan language must have been adopted by June 30, 2020.

Edition

Each page footer prints Form 15417 (4-2023), Catalog Number 94028G, publish.no.irs.gov, Department of the Treasury - Internal Revenue Service.

Part of a series

The IRS listing titles Forms 15417-A through 15417-I as further worksheets in the Determination of 403(b) Status series.

Related forms

Who completes Form 15417?

  • Not stated on the form

    No line names a preparer, a reviewer or a recipient, and there is no signature line. The only entry at the top is the name of the plan.

  • Applications under the 2021 RA List

    The header on both pages reads "For applications submitted to conform to the 2021 RA List."

  • Church and QCCO sponsors

    Item III(a) asks whether the plan sponsor is a church or QCCO. If yes, the form says to skip the rest of the worksheet.

  • Non-QCCO, government and other tax-exempt sponsors

    Item III(a) says that if the sponsor is a non-QCCO, government, or other tax-exempt entity, the universal availability section applies.

  • Section IV exclusions

    Item IV(a) says that if the plan sponsor is a church, QCCO, or governmental entity (e.g. public school), section IV is not completed.

The worksheet does not name who completes it or who receives it. Some answers end it early or skip a section.

Official sources and the blank

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Questions about Form 15417

Who fills out Form 15417?

The worksheet does not say. It asks about the provisions of a named 403(b) plan and has no preparer, signature or recipient lines.

What does a No answer mean on this worksheet?

The form says a "Yes" answer generally indicates a favorable conclusion is warranted, while a "No" answer indicates a problem exists. Each section has space to explain any "No" answer.

Does it apply to church plans?

Item III(a) asks whether the plan sponsor is a church or QCCO and says that if yes, skip the rest of this worksheet.

What is the OIAI rule on this worksheet?

Item III(e) asks whether an employee who has satisfied the service conditions for a year remains eligible even if hours are reduced below the minimum level, which the form calls the Once-In-Always-In Rule.

Which worksheet is "WS 11a"?

Item III(b) refers to "WS 11a, Elective Deferrals for 403(b)." In the IRS listing, Form 15417-F is Worksheet 11A for matching and employee after-tax contributions, and Form 15417-G is the Elective Deferrals Worksheet 12A.

Are there separate instructions for Form 15417?

No separate instructions are linked to it. The directions are the paragraph at the top of page 1 and the notes under individual items.