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B. No Surviving Spouse or Surviving Dependents <br />If there are no living spouse or dependents at the time of death of the Participant, the account will revert to the Plan to <br />be applied as specified in Section VIII. <br />XII. The Plan will operate according to the following provisions: <br />A. Employer Responsibilities <br />1. The Employer will submit all VantageCare Retirement Health Savings Plan contribution data via electronic submission. <br />2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal <br />information updates via electronic submission. This includes but is not limited to termination notification and <br />benefit eligibility notification. <br />B. Participant account administration and asset -based fees will be paid through the redemption of Participant account <br />shares, unless agreed upon otherwise in the Administrative Services Agreement. <br />C. Assignment of benefits is not permitted. Benefits will be paid only to the Participant, his /her Survivors, the <br />Employer, or an insurance provider (as allowed by the claims administrator). Payments to an third -party payee <br />(e.g., medical service provider) are not permitted with the exception of reimbursement to the Employer or insurance <br />provider (as allowed by the claims administrator). <br />D. An eligible dependent is the Participant's lawful spouse and any other individual who is a person described in IRC <br />Section 152(a), as clarified by Internal Revenue Service Notice 2004 -79. <br />E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which <br />are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare Retirement Health <br />Savings Plan Employer Manual. <br />XIII. Employer Acknowledgements <br />A. The Employer hereby acknowledges it understands that failure to properly fill out this Employer VantageCare <br />Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and /or loss <br />of tax- deferred status for Employer contributions. <br />B. © ( ,heck this box if you are including supporting documents that include plan provisions. <br />EMPLOYER SIGNATURE <br />By: �` �� x - — Date: /�� (2y <br />Tit Y "City Manager <br />Attest: <br />Title: <br />Accepted: VAN l'A(;EPOINT TRANSFER AGENTS, LLC <br />-. f <br />Assistant Srcrctan 1(.N- I.A -RC <br />Date: <br />APPROVED AS TO FORM <br />LISA E. STORCK <br />Assistant City Attorney <br />ATTEST: <br />MARIA D. HUIZAR✓ <br />CLERK OF THE COUNCIL <br />MR 1 5 2412 <br />