15417-G

403(b) Plan Elective Deferrals Worksheet 12A – Determination of 403(b) Status

Agency
IRS
Revision
4-2023
Fillable fields
88
Pages
2
Official source
IRS form page
Checked
October 21, 2026
Fill 15417-G online
Page 1 of form 15417-G

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

Form 15417-G (4-2023) is a two-page IRS worksheet titled 403(b) Plan Elective Deferrals. Its title also calls it Worksheet 12A, Determination of 403(b) Status. It goes through a named 403(b) plan's elective deferral terms in six sections: applicability, contributions, limits and catch-ups, universal availability, vesting, and eligible automatic contribution arrangements (EACAs). 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 (except for cross-references, which are shaded to indicate no answer is required)." A "Yes" answer generally indicates a favorable conclusion is warranted, while a "No" answer indicates a problem exists. 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-G

Section I: Applicability

Whether the plan offers elective deferrals and whether elective deferrals are properly defined under the plan.

Section II: Contributions

A cross-reference to WS 1a on eligibility, then three questions on designated Roth contributions: irrevocable designation, inclusion in income, and separate accounting from pre-tax elective deferrals.

Section III: Limits and Catch-Ups

Four cross-references to Worksheet 6A (Limits): the section 402(g)(1) basic limit, the age 50 and special section 403(b) catch-ups, excess deferrals, and the definition of compensation.

Sections IV and V

Cross-references to Worksheet 1A for universal availability under 1.403(b)-5(b), and to Worksheet 2B for vesting.

Section VI: EACAs

Items a to i on covered employees, the uniformity of the default percentage, notice, permissible withdrawals and their fees, the 402(g) limit, matching contributions, and the time to distribute excess aggregate contributions.

How to fill out Form 15417-G

  1. 1

    Name of plan

    Enter the name of the 403(b) plan in the box at the top of page 1.

  2. 2

    Start with Section I

    Answer item I(a). The form says a "No" means skipping this worksheet and a "Yes" means going on to I(b).

  3. 3

    Cross-references

    The instructions say cross-references are shaded to indicate no answer is required. Sections III, IV and V consist of items that point to Worksheets 6A, 1A and 2B.

  4. 4

    Check Yes, No or N/A

    Check one box for each remaining item. Each row also has a Plan Reference column; the form gives no further directions for it.

  5. 5

    Section VI only with EACA provisions

    Complete Section VI if the plan contains EACA provisions. Items VI(e) and VI(f) begin with "If applicable".

  6. 6

    Explain any No answers

    Sections I, II and VI end with a space headed Explain any "No" answers in this section. The instructions at the top say to use it for every "No".

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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

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.

Edition

Each page footer prints Form 15417-G (4-2023), Catalog Number 94035V, Department of the Treasury, Internal Revenue Service.

Part of a series

The title calls it Worksheet 12A. It points to Worksheets 1A, 2B, 6A and 15, which the IRS listing titles as Forms 15417, 15417-A, 15417-D and 15417-H.

Related forms

Who completes Form 15417-G?

  • 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.

  • Plans that offer elective deferrals

    Item I(a) asks whether the plan offers elective deferrals. The form says that if the answer is "No," the worksheet is skipped, and if "Yes," item I(b) comes next.

  • Plans that accept designated Roth contributions

    Section II asks whether Roth contributions are designated irrevocably at the time of the election, treated as includible in income, and accounted for separately from pre-tax deferrals.

  • Plans with an EACA

    Section VI is completed if the plan contains EACA provisions. Item VI(a) says that if the plan does not provide an EACA, the section is skipped.

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.

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Questions about Form 15417-G

Who fills out Form 15417-G?

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

What if the plan offers no elective deferrals?

Item I(a) says that if the plan does not offer elective deferrals, the worksheet is skipped.

Do the cross-reference items need an answer?

The instructions say cross-references are shaded to indicate no answer is required.

Where are the deferral limits and catch-ups covered?

Section III points to Worksheet 6A (Limits) for the section 402(g)(1) basic limit, the age 50 and special section 403(b) catch-ups, excess deferrals and the definition of compensation.

What does item VI(i) ask?

If all participants are covered employees, it asks whether the plan states it has until 6 months (rather than 2½ months) after the end of the plan year to distribute excess aggregate contributions and avoid the Code § 4979 10% excise tax.

Where are distributions of elective deferrals covered?

A note at the end of Section VI says to see WS 15 for requirements of distributions concerning elective deferrals. The IRS listing titles Form 15417-H as Worksheet 15.