15417-B
403(b) Plan Miscellaneous Provisions Worksheet 4A – Determination of 403(b) Status
Form 15417-B (4-2023) is a three-page IRS worksheet titled 403(b) Plan Miscellaneous Provisions. Its title also calls it Worksheet 4A, Determination of 403(b) Status. It goes through a named 403(b) plan in four sections: terminations; rollover contributions, exchanges and transfers; funding issues; and general issues. Each question has a Plan Reference column and Yes, No and N/A boxes.
The instructions printed at the top of page 1 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. A few items are marked optional. 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.
Full vesting and distribution on plan termination, optional in-kind distribution of an individual custodial account, the 12-month limit on contributions to an alternative 403(b) contract, and contributions after an employer stops being eligible.
Whether the plan accepts eligible rollover distributions, section 72 basis information, designated Roth rollovers and in-plan Roth rollovers, with a note pointing to Worksheet 15 for more rollover rules.
Recontributions of qualified birth or adoption, coronavirus-related and federally declared disaster distributions, plan-to-plan transfers, transfers to a qualified plan and contract exchanges among vendors.
Investment in an annuity contract, custodial account or retirement income account, the requirements of section 1.403(b)-8, and transfer of contributions to the vendor within a reasonable or specified period.
Qualified military service under section 414(u), benefits for survivors of participants who die on military service, the exclusive benefit rule for custodial accounts, and domestic relations orders.
Enter the name of the 403(b) plan in the box at the top of page 1.
Check one box for each item. Each row also has a Plan Reference column; the form gives no further directions for it.
Items I(b) and II(j)(iv) are marked optional. Item I(c) is marked optional, but required if the plan allows ICA distributions.
Item II(a) says that if rollovers are not accepted, items II(b) through (d) are not completed. The note under II(e) says a plan that allows QBADs defines eligible adoptee as excluding children of the taxpayer's spouse.
Each of the four sections ends with a space headed Explain any "No" answers in this section. The instructions at the top say to use it for every "No".
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The worksheet prints no mailing address, filing method, recipient or deadline, and it has no signature line.
No IRS About page or instructions are linked to it. The directions are the paragraph at the top of page 1 and the notes printed under some items.
Each page footer prints Form 15417-B (4-2023), Catalog Number 94030S, Department of the Treasury, Internal Revenue Service.
The title calls it Worksheet 4A in the Determination of 403(b) Status series. The IRS listing titles Form 15417-H as Worksheet 15 and Form 15417-I as Worksheet 16, the two worksheets this form names.
15417-H
257 fields, 5 pages
15417-I
88 fields, 3 pages
15417
81 fields, 2 pages
15417-A
26 fields, 1 page
15417-C
104 fields, 3 pages
15417-D
105 fields, 3 pages
The worksheet does not name who completes it or who receives it. Its questions ask what a 403(b) plan document provides, not about a person's own taxes.
No tool matches that search.
The worksheet does not say. It asks about the provisions of a named 403(b) plan and has no preparer, signature or recipient lines.
Item I(a) asks whether all accumulated benefits will be fully vested and distributed as soon as administratively practicable. Item I(d) asks whether the employer or a related employer may not contribute to an alternative 403(b) contract from plan termination until 12 months after all assets are distributed, and notes a 2% exception.
Item II(a) says that if rollovers are not accepted, items II(b) through (d) are not completed.
Items I(b) and II(j)(iv) are marked optional. Item I(c) is marked optional, but required if the plan allows ICA distributions.
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.
No separate instructions are linked to it. The directions are the paragraph at the top of page 1 and the notes under individual items.