15417-H

403(b) Plan Distributions Worksheet 15 - Determination of 403(b) Status

Agency
IRS
Revision
4-2023
Fillable fields
257
Pages
5
Official source
IRS form page
Checked
October 21, 2026
Fill 15417-H online
Page 1 of form 15417-H

Form 15417-H: 403(b) Plan Distributions Worksheet 15

Form 15417-H (4-2023) is a five-page IRS worksheet titled 403(b) Plan Distributions. Its title also calls it Worksheet 15, Determination of 403(b) Status. It goes through a named 403(b) plan in eight sections: permissible distribution events for elective deferrals, for employer contributions in annuity contracts or retirement income accounts, for employer contributions in 403(b)(7) custodial accounts, for after-tax employee contributions and for rollover contributions, then loans, rollovers and cash outs, and miscellaneous. 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." A "Yes" answer generally indicates a favorable conclusion is warranted, while a "No" answer indicates a problem exists. Several notes on the form are headed Note to Reviewer.

The worksheet does not name a preparer or recipient, 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-H

Section I: Elective deferrals

Separate accounts, the general events (death, disability, severance from employment, age 59½ and hardship), and special situations such as plan termination, QDRO, IRS levy and qualified birth or adoption distributions.

Section II: Annuity contracts

Distribution events for employer contributions in annuity contracts or retirement income accounts, including severance from employment, a prior event such as a fixed number of years, and excess employer contributions.

Section III: Custodial accounts

Distribution events for employer contributions from 403(b)(7) custodial accounts: death, disability, severance from employment, age 59½, and special situations.

Sections IV and V

When after-tax employee contributions may be distributed, and whether a participant may at any time take a distribution from a separate rollover account.

Section VI: Loans

Whether the plan allows loans, a fixed repayment schedule, a reasonable rate of interest, repayment safeguards, who is responsible for Code compliance, and the 72(p) limits.

Sections VII and VIII

Direct rollovers, mandatory distributions, nonspouse beneficiary rollovers to an inherited IRA, the 402(f) written explanation, and the definition of severance from employment.

How to fill out Form 15417-H

  1. 1

    Name of plan

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

  2. 2

    Events the plan leaves out

    The notes to reviewer say not all listed events need to be in the plan. They say to use N/A if an event is not included and No if it is not properly included, for example using age 59 instead of 59½.

  3. 3

    Hardship items

    Under item I(b)(v), answer A on whether hardship distributions are permitted, then B for the safe harbor standard or C for an alternative standard that is nondiscriminatory and based on objective criteria.

  4. 4

    Loans and mandatory distributions

    Use N/A for Section VI if the plan does not permit participant loans. Item VII(b) is completed only if the plan provides for mandatory distributions.

  5. 5

    Plan Reference column

    Each row has a Plan Reference column next to the Yes, No and N/A boxes. The form gives no further directions for it.

  6. 6

    Explain any No answers

    Each section ends 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.

Dollar amounts on the form

Item VII(a) refers to eligible rollover distributions of at least $500, and item VII(b) to mandatory distributions greater than $1,000.

Edition

Each page footer prints Form 15417-H (4-2023), Catalog Number 94036G, Department of the Treasury, Internal Revenue Service.

Part of a series

The title calls it Worksheet 15. It points to Worksheet 6A for excess employer contributions, which the IRS listing titles as Form 15417-D.

Related forms

Who completes Form 15417-H?

  • A reviewer, per its notes

    There is no preparer line, signature line or recipient. Several notes are headed Note to Reviewer, and the only entry at the top is the name of the plan.

  • Plans with a separate elective deferral account

    Item I(a) says that if elective deferrals are kept in a separate account, the only distribution restrictions for that account are the ones in Section I.

  • Annuity contracts and retirement income accounts

    Section II covers employer contributions held in an annuity contract or retirement income account, such as nonelective and matching contributions.

  • 403(b)(7) custodial accounts

    Section III covers the same kinds of employer contributions when they are held in 403(b)(7) custodial accounts.

  • Plans that permit loans

    Section VI covers participant loans. The note to reviewer says to use N/A for the section if the plan does not permit participant loans.

The worksheet does not name a preparer or a recipient. Its notes are addressed to a reviewer, and 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-H

Who fills out Form 15417-H?

The worksheet does not name a preparer or recipient. Several notes are headed Note to Reviewer, and every item asks what a named 403(b) plan provides.

How are events the plan does not include answered?

The notes to reviewer say to use N/A if an event is not included in the plan and No if it is not properly included, for example using age 59 instead of 59½.

What if the plan does not permit loans?

The note in Section VI says to use N/A for the section if the plan does not permit participant loans.

What does Section VII ask about rollovers?

It asks about direct rollovers of eligible rollover distributions of at least $500, mandatory distributions greater than $1,000, nonspouse beneficiary rollovers to an inherited IRA and the 402(f) written explanation.

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.

Are there separate instructions for Form 15417-H?

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