Form 14704
Catalog Number 67750Hwww.irs.gov
Form
14704 (5-2015)
Form 14704
(May 2015)
Department of the Treasury - Internal Revenue Service
Transmittal Schedule – Form 5500-EZ
Delinquent Filer Penalty Relief Program
(Revenue Procedure 2015-32)
(Attach to Oldest Delinquent Return in this Submission)
OMB Number
1545-0956
1. Applicant’s name (plan sponsor or plan administrator)
2. Applicant's street address
3. City or town, state and zip code (include foreign country name, province/county and zip code, if applicable)
4. Applicant’s Employer Identification Number (do not use a Social Security Number)5. Applicant’s telephone number
6. Plan number7. Plan name
8. Indicate the last day of the plan year for each delinquent return included in this submission (enter MM/DD/YY)
9. Check the applicable box below for the amount of payment
Number of Delinquent Returns in this SubmissionAmount of Payment (choose one)
(a) One delinquent return$500
(b) Two delinquent returns$1,000
(c) Three or more delinquent returns$1,500
