CYCLE E 

Form 13069 

(March 2010) 

Department of the Treasury – Internal Revenue Service 

Employee Benefit Plan 

Section 401(h) 

(Worksheet Number 13 – Determination of Qualification) 

Date 

INSTRUCTIONS - All items must be completed. A “Yes” answer generally indicates 

a favorable conclusion is warranted, while a “No” answer indicates a problem exists. 

Please use the space on the worksheet to explain any “No” answer. See Publication 

11433, Explanation Number 13, for guidance in completing this form 

The technical principles in this worksheet may be 

changed by future regulations or guidelines 

Name of Plan 

I. Benefits Plan Reference Yes No N/A 

a. Has the applicant requested consideration under section 401(h) or 420? If 

“Yes,” see section 16 and appendix of Rev. Proc. 2006-6, 2006-1 I.R.B. 204, 

and complete the remainder of this worksheet. If “No,” do not complete the 

remainder of this worksheet. [1375] 

b. Does the plan contain a medical benefits account within the meaning of 

section 401(h)? If “Yes,” complete the remainder of this worksheet. If “No,” 

secure amendments to include the section 401(h) account provisions or 

request an explanation from the applicant. [1375] 

c. Is the section 401(h) account part of a pension or annuity plan (including a 

money purchase pension plan)? [1376] 

d. Does the plan specify the medical benefits that will be available and 

contain provisions for determining the amount that will be paid? [1376] 

e. Does the medical benefits account specify who will benefit and limit eligible 

persons to retired employees, their spouses and their dependents? [1377] 

f. Does the plan specify either that contributions to such account are provided 

entirely from employer contributions or that they will be paid from employer 

and employee contributions? [1378] 

II. Subordination Plan Reference Yes No N/A 

a. Does the plan provide that retiree medical benefits are subordinate to the 

retirement benefits such that the aggregate actual contributions for medical 

benefits, when added to actual contributions for life insurance protection 

under the plan, do not exceed 25 percent of the total actual contributions to 

the plan (other than contributions to fund past service credits) after the later of 

the adoption or effective date of the plan amendment establishing the section 

401(h) account? [1379] 

III. Separate Accounts Plan Reference Yes No N/A 

a. Does the plan provide that the section 401(h) arrangement is a separate 

account established and maintained for such benefits? [1380] 

Form 13069 (Rev. 3-2010) (Page 1) Cat. No. 31858W www.irs.gov Department of Treasury - Internal Revenue Service 
 

 

 

 

 

 

 

 

CYCLE E 

III. Separate Accounts – Continued Plan Reference Yes No N/A 

b. Does the plan provide that in the case of an employee who is a key 

employee, a separate account is established and maintained for benefits 

payable to such employee (and his spouse and dependents) and such 

benefits (to the extent attributable to plan years beginning after March 31, 

1984, for which the employee is a key employee) are only payable to such 

employee (and his spouse and dependents) from such separate account? 

[1381] 

c. Does the plan provide that the term “key employee” means any employee, 

who at any time during the plan year or any preceding plan year during which 

contributions were made on behalf of such employee, is or was a key 

employee as defined in section 416(i)? [1381] 

IV. Reasonable and Ascertainable Provisions Plan Reference Yes No N/A 

a. Does the plan provide for employer contributions to the medical benefits 

account that are reasonable and ascertainable? [1382] 

V. Miscellaneous Plan Reference Yes No N/A 

a. Does the plan provide that it is impossible, at any time prior to the 

satisfaction of all liabilities under the plan to provide section 401(h) medical 

benefits, for any part of the corpus or income of such separate account to be 

(within the taxable year or thereafter) used for, or diverted to, any purpose 

other than the providing of such benefits? [1383] 

b. Does the plan expressly provide that, notwithstanding the provisions of 

section 401(a)(2), upon the satisfaction of all liabilities under the plan to 

provide section 401(h) medical benefits, any amount remaining in such 

separate account must be returned to the employer? [1384] 

c. Does the plan expressly provide that in the event an individual’s interest in 

the medical benefits account is forfeited prior to termination of the plan an 

amount equal to the amount of the forfeiture must be applied as soon as 

possible to reduce employer contributions to fund the medical benefits? 

[1385] 

Form 13069 (Rev. 3-2010) (Page 2) Cat. No. 31858W www.irs.gov Department of Treasury - Internal Revenue Service