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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 au 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 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. ❑ Check this box if you are including supporting documents that include plan provisions. <br />EMPLOYER SIGNATURE <br />By: 0e I Date: <br />E cutive Director. Pe services <br />Date: <br />Clerk of the Council <br />Accepted: VANTAGEPOINTTRANSFER AGENTS, LLC APPROVED AS TO FORM <br />}J" ISA .STORC� r"'z <br />Assistant City Attorney <br />Assistant A ecretary ICMA-RC <br />IaTTESr <br />M4RAD A <br />CLERK OF THE COU .IL <br />