15417-I

403(b) Plan 403(b)(9) Retirement Income Accounts Worksheet 16 –Determination of 403(b) Status

Agency
IRS
Revision
4-2023
Fillable fields
88
Pages
3
Official source
IRS form page
Checked
October 21, 2026
Fill 15417-I online
Page 1 of form 15417-I

Form 15417-I: 403(b)(9) Retirement Income Accounts, Worksheet 16

Form 15417-I is titled "403(b) Plan, 403(b)(9) Retirement Income Accounts, Worksheet 16, Determination of 403(b) Status." It is a checklist that walks through the written terms of a 403(b)(9) retirement income account plan, item by item. The form says that if the plan is a 403(b)(9) retirement income account plan, this worksheet is used first, and that it also notes special rules that apply to 403(b)(9)s in regard to requirements on other worksheets.

Each item is a question about the plan document, with a Plan Reference column and boxes for Yes, No or N/A. The form says "All items must be completed," that a "Yes" answer generally indicates a favorable conclusion is warranted, and that a "No" answer indicates a problem exists. It has seven sections: applicability, employer and employee eligibility, requirements to be a 403(b)(9) retirement income account, funding vehicles, nondiscrimination, limits and distributions.

The worksheet does not say who completes it and prints no filing address or deadline. It also says its technical principles may be changed by future regulations or guidelines. You can fill out Form 15417-I free in your browser on this page and download the result without an account.

What's on Form 15417-I

Plan name and answer columns

A line for the name of the plan, then every item has a Plan Reference column and Yes, No and N/A boxes. Each section ends with space to explain any "No" answers.

Sections I and II: applicability and eligibility

Whether the plan is a defined contribution retirement income account, whether the adopting employer is a church-related organization, and who is eligible to participate.

Section III: account requirements

Items a to d: separate accounting for the account's interest in plan assets, investment performance based on those assets, the exclusive benefit rule, and loans or credit to the employer treated as diverted assets.

Section IV: funding vehicles

Commingling in a common fund only with amounts devoted exclusively to church purposes, and the four kinds of trust assets that may be invested in a group trust.

Sections V and VI: nondiscrimination and limits

Section V points to Worksheets 1A, 11A, 5B and 6A when the employer is not a church or QCCO. Section VI points to Worksheet 6A for limits, including special rules for "denominational service".

Section VII: distributions

Life annuity present value and benefit guarantee rules of section 1.403(b)-9(a)(5), distribution limits that follow annuity contract rules, and ownership or use of account assets treated as a distribution.

How to fill out Form 15417-I

  1. 1

    Start with this worksheet

    The form says to use this worksheet first if the plan is a 403(b)(9) retirement income account plan. Enter the name of the plan at the top.

  2. 2

    Answer each item

    For each question, enter where the plan document addresses it in the Plan Reference column and check Yes, No or N/A.

  3. 3

    Follow the notes in Section IV

    Answer IV(a) N/A if the plan does not provide for commingling in a common fund, and No if it does but does not limit it to amounts devoted exclusively to church purposes. Answer IV(b) N/A if the plan does not use a group trust.

  4. 4

    Use the skip rule in Section V

    If 403(b) elective deferrals are the only contributions, the form says to skip Section V. If not, item V(b) asks about nondiscrimination language when the employer is not a church or QCCO.

  5. 5

    Check the other worksheets

    Sections V, VI and VII refer to Worksheets 1A, 5B, 6A, 11A and 15 for related rules. The form says this worksheet also notes special rules that apply to 403(b)(9)s on those other worksheets.

  6. 6

    Explain each No answer

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

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Notes printed on the worksheet

No filing details

The worksheet prints no filing address, deadline or instructions about where it goes. Its footer gives the catalog number 94037R.

What the answers mean

The form says a "Yes" answer generally indicates a favorable conclusion is warranted, while a "No" answer indicates a problem exists.

Rules may change

The form says the technical principles in this worksheet may be changed by future regulations or guidelines.

Other worksheets

The form names Worksheets 1A (Eligibility), 5B, 6A (Limits), 11A and 15 (Distributions). The IRS listing titles Forms 15417, 15417-C, 15417-D, 15417-F and 15417-H as those worksheets.

Related forms

Which plans and employers Form 15417-I covers

  • 403(b)(9) retirement income account plans

    Section I asks whether the account is a defined contribution program and whether the plan specifically states it is intended to constitute a retirement income account under section 403(b)(9).

  • Churches, conventions and church schools

    Item II(a)(i) lists a church, a convention or association of churches, or an elementary or secondary school of such (see section 3121(w)(3)(A)).

  • Church boards and QCCOs

    Items II(a)(ii) and (iii) list a church retirement/welfare board if controlled or associated with a church, and a qualified church-controlled organization.

  • Self-employed ministers and chaplains

    Item II(a)(iv) lists a self-employed minister or chaplain, but solely with respect to a retirement income account established for that minister or chaplain.

  • Employees and beneficiaries

    Item II(b) asks whether eligibility is limited to employees of a church-related organization (including a Non-QCCO) and their beneficiaries, including self-employed ministers and chaplains.

The worksheet does not name who fills it out. It reviews the terms of a 403(b)(9) retirement income account plan and the employers and employees that plan may cover.

Official sources and the blank

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Questions about Form 15417-I

When is Form 15417-I used first?

The form says that if the plan is a 403(b)(9) retirement income account plan, this worksheet is used first.

What does a No answer on Form 15417-I mean?

The form says a "No" answer indicates a problem exists, and each section has space to explain any "No" answers.

Which employers does item II(a) list?

A church, a convention or association of churches, or an elementary or secondary school of such; a church retirement/welfare board; a qualified church-controlled organization; and a self-employed minister or chaplain for their own account.

When is the nondiscrimination section skipped?

The form says to skip Section V if 403(b) elective deferrals are the only contributions.

Where is Form 15417-I sent?

The worksheet does not say. It prints no filing address, deadline or separate instructions.