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DocuSign Envelope ID: 10DC72A2-A9C6-40FB-A2DC-2AB28AF423E9 EXHIBIT A-1 to Third Amendment Plan Design Change -Consolidated Appropriations Act, 2021 The purpose of this form is to collect all information necessary to update your Plan design in response to COVID-19. Overview The Consolidated Appropriations Act, 2021 allows clients to electively adopt any combination of the following changes: • Allow unlimited carryover of funds from plan year ending in 2020 and in 2021 for the following account types: o Health FSA o Dependent Care Assistance Plans (DCA) • Extend a Grace Period that ended in 2020 or will end in 2021 to a full 12-month period following the original plan year end date for the following account types: o Health FSA o DCA • Extend previously adopted relaxed change in status rules so that they apply for the plan year ending in 2021 or adopt them for the first time for the plan year ending in 2021. For new adopters, changes are prospective. • Allow employees who terminated in 2020 or 2021 to spend down balances in their Health FSA. • Allow reimbursement for daycare expenses for children up to the age of 14 if the dependent aged out (turned 14 during the previous plan year, provided that enrollment in the DCA took place on or prior to January 1, 2020. To make these changes, a Plan Amendment is required but does not need to be completed until December 31, 2021. As a result, employers have time to consider what changes they wish to apply to their plan even when those changes are retroactive to plan years ending in 2020. Employer may wish to review their final run out activity reporting before making any retroactive plan design changes. Please note that Igoe will automatically update claim management to allow qualified account holders to claim dependent care reimbursement for children up to the age of 14. No action is needed on your part. To ease the review and adoption process, Igoe has put together a preferred plan design option for your review within this Statement of Work. Instructions 1. Please complete the following form in its entirety. Basic Client Information Company Name (Client):City of Santa Ana Plan Design Change CAA 2021 COVID-19—SOW: Page 1 iC UE © Igoe Administrative Services