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VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) <br />ADOPTION AGREEMENT <br />Plan Number: 8 03550 <br />Select as applicable: ❑ Standalone RHS ❑ lnregtated RI -IS [{Z Amendment to Existing Plan ❑Now Plan <br />I. EmployerNamaa City of Santa Ana State: CA <br />II. 'Ilia Employer herebyattests that it is a unit of a state or local government of an agency or instrumentality of one of <br />more units of a state or local government. <br />Ili. Plan Antes: <br />A. Plan Effective Dare 5/=19,_,,,e__„___ <br />B. P1ati Vear: Enter the annual accountlug period for the RI IS program. _ <br />IV, The Employer intends to atilixe the. Trust to fiend only welfare benefits pursuant to the following welfare benefit <br />plan(s) established by the Employer: Citv of Santa Ana Retiree Wad <br />V. Eligible Croups, 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 1V. (check all applicable boxes): <br />❑ All Employees <br />❑ All Pull Thr e Employees <br />❑ Non -Union Employees <br />❑ PublicSafetpEmployees— Police <br />❑ Public Safety Employees — Firefighters <br />❑ General Employees <br />❑ Collectively -Bargained Employees (Specify unh(s)) _ <br />0 Other (specifygroup(s)) CltV Manager <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 />AfaueMtoty Pdrticipat;on: 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 Employees u ndulyingwelfare benefit plan is in whale or part a non -collectively bargained plan that allows' <br />reimbursement for medical expenses other than insurance premiums, the nondiscrimination rcquircments of <br />Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received <br />by highly compensated individuals if the Plan discriminates in favw of highly compensated lodividuals !it terms of i <br />eligibility or benefits. The Employer should discuss these rules with appropriate counsel, <br />11:13 <br />