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VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) <br />ADOPTION AGREEMENT <br />Plan Number: g 03550 <br />Select as applicable: ❑ Standalone RHS ❑ Integrated RHS ® Amendment to Existing Plan ❑ New Plan <br />I. Employer. Namr City of Santa Ana State: CA <br />II. The Employer hereby attests that it is a unit of a state or local government or as agency or instrumentality of one or <br />more units of a state or local government. <br />III. Plan Dates: <br />A. Plan Effective Bate 12019 <br />B. Plan Year: Enter the annual accounting period for the RHS program <br />IV The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit <br />plan(s) established by the EmploynnCily Of Santa Ana RP.tiPBe Wd <br />V. Eligible Groups, Participation and Participant Eligibility Requirements <br />A. Eligible Groups <br />The following group or groups of Employees are eligible to participate in the Employer's welfare benefits plan identified <br />in Section IV. (check all applicable boxes): <br />❑ All Employees <br />❑ All Full -Time Employees <br />❑ Non -Union Employees <br />❑ Public Safety Employees — Police <br />❑ Public Safety Employees — Firefighters <br />❑ General Employees <br />❑ Collectively -Bargained Employees (Specify unit(s)) <br />❑ Other (specify group(s)), it)(,MgInager <br />The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, <br />ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of <br />the Employer. <br />B. Participation <br />Mandatory Participation: All Employees in the covered group(s) are required to participate in <br />the Plan and shall receive contributions pursuant to Section VI. <br />If the Employer's underlying welfare benefit plan is in whole or part a non -collectively bargained plan that allows <br />reimbursement for medical expenses other than insurancepremiums, the nondiscrimination requirements of <br />Internal Revenue Code (IRC) Section 10$(h) will; apply.. These rules may impose taxation on the benefits received <br />by highly compensated individuals if the Plan discriminates in favor of highly compensated individuals in terms of <br />eligibility or benefirs. The Employer should discuss these rules with appropriate counsel <br />II:13 <br />