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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 (a) the Participant's lawful spouse, (b) the Participant's child under the age of 27, as defined <br />by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010 -38, or (c) any other individual who is a person <br />described in IRC 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 chat failure to properly fill out this Employer VantageCarc <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 Employee contributions. <br />B. Vj Check this box if you arc including supporting documents that include plan provisions. <br />Accepted: VANTAGEPOINT TRANSFER AGENTS, LLC <br />; 6CA. C, i)I� - <br />Assistant Secretary, ICMA -RC <br />Date: 9/(3 l <br />Date: <br />