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Plan Number: <br />SUGGESTED AFFIRMATIVE STATEMENT FOR AMENDMENT OF THE <br />VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM <br />03550 <br />Name of Employer: City Of Santa Ana State: <br />Affirmative Statement of the above-named Employer (the "Employer"): <br />WHEREAS, the Employer has employees rendering valuable services; and <br />CA <br />WHEREAS, the amendment of its existing retiree health savings plan serves the interests of the Employer and <br />its Employees; and <br />NOW THEREFORE, as a duly authorized agent of the Employer, I hereby: <br />AMEND the Employer's Plan in the form of the SCMA Retirement Corporation's VantageCare Retirement <br />Health Savings program. <br />DATE: <br />Tide of Designated Agent <br />Signature <br />Afr 30662-091(rW412 <br />