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Form 13070 

(March 2010) 

Department of Treasury – Internal Revenue Service 

Employee Plans Deficiency Checksheet 

Attachment #13 

Section 401(h)

Date 

For IRS Use Please furnish the amendment(s) requested in the section(s) checked 

1.a.b. For a section 420 transfer of excess assets to retiree health accounts, the plan must be amended to include 

provisions for a medical benefits account within the meaning of section 401(h). IRC section 420(e)(3). 

1.c.d. A pension or annuity plan containing a section 401(h) account may only provide medical benefits including 

payment of benefits for sickness, accident, hospitalization and medical expenses. Section _______ of the plan 

should be amended to specify the medical benefits which will be available, the amount which will be paid and 

when the payments will occur. IRC section 401(h); Treas. Regs. 1.401-1(b)(1)(i); 1.401-14(a) and (c)(1). 

I.e. Section_______ of the plan should be amended to specify who is eligible to receive medical benefits from the 

section 401(h) account. Note that benefits may only be provided to retired employees, their spouses and their 

dependents. IRC section 401(h); Treas. Regs. 1.401-14(a), (b)(1) and (b)(2). 

I.f. Section ________ of the plan should be amended to provide whether contributions to the section 401(h) 

account are provided entirely from employer contributions or whether they will be paid from employer and 

employee contributions. Treas. Reg. 1.401-14(b)(3). 

II.a. Section _______ of the plan should be amended to provide that the aggregate actual contributions for retiree 

medical benefits, when added to the actual contributions for life insurance under the plan, are limited to 25 

percent of the total actual contributions made to the plan (other than contributions to fund past service credits) 

after the later of the adoption or effective date of the section 401(h) arrangement (note that the date of 

adoption is the date the employer signs or executes the section 401(h) amendment). IRC section 401(h); 

Treas. Reg. 1.401-14(c)(1)(i). 

III.a. Section ________ of the plan should be amended to provide that a separate account is established and 

maintained with respect to contributions to fund medical benefits under the section 401(h) arrangement. IRC 

section 401(h)(2); Treas. Reg. 1.401-14(c)(2). 

III.b.c. Section _______ of the plan should be amended to provide that in the case of an employee who is a key 

employee (as defined in IRC section 416(i)), 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. IRC section 401(h)(6). 

IV.a. Section ________ of the plan should be amended to provide that the employer’s contributions to the medical 

benefits account are reasonable and ascertainable and that the employer must, at the time a contribution is 

made, designate that portion of such contribution allocable to the funding of medical benefits. In addition, 

section of the plan should be amended to specify the amounts of benefits, the priority and the time period with 

respect to which benefits which will be paid from each source, when other sources of payment for such medical 

benefits exist, such as a welfare benefit fund (for example, a section 501(c)(9) voluntary employees beneficiary 

association) or the general funds of the employer. IRC section 401(h)(3); Treas. Reg. 1.401-14(c)(1) and (3). 

Form 13070 (Rev. 3-2010) (page 1) Cat. No. 31859H Department of Treasury – Internal Revenue Service
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Form 13070 (Rev. 3-2010) (page 2) Cat. No. 31859H Department of Treasury – Internal Revenue Service

V.a. Section _______ of the plan should be amended to provide that it is impossible, at anytime 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. IRC section 401(h)(4); Treas. Reg. 1.401-14(c)(4). 

V.b. Section _______ of the plan should be amended to provide, notwithstanding the provisions of section 401(a)(2), 

that 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. IRC section 401(h)(5); Treas. Reg. 

1.401-14(c)(5). 

V.c. Section ________ of the plan should be amended to 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. 

Treas. Reg. 1.401-14(c)(6).