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Vantage(are Retirement Health Savings Plan <br />r Implementation Data Form — Page 1 <br />,< ICMA 1-Z" Instructions to Employer: Provide necessary information to establish your plan propedy. <br />Building Ratim,ne», s,,,,,iry Please contact your New Business Analyst at 1-800-326-7272, If you have any questions. <br />ICMA-RC Use Only: Employer # <br />General Information 1. (902) Employer's Full Name: City of Santa Ana (Executive Management RHS Plan) <br />2. (924) Street Address: 20 Civic Center Plaza, M-34 <br />(9P5) P.O. Box 1988, M-34 <br />3. (918) Gty: Santa Ana <br />(919) State: CA _ (920) Zip Code: 92702 <br />4. (633)Primay(ontact: Kathleen Crook <br />S. (634)Primmy(omactTitle: Benefits & Compensation Supervisor <br />6. (631) Primary Contact Telephone #: (714) 647-6967 <br />7. (632) Fax#: (714 ) 647-5321 <br />B. (PT00)E-mail address: kcrook@santa-ana.org <br />This email will be used to provide an electronic copy of your plan summary. <br />9. (882) Employer's Federal Tax Identification Number: 95-6000785 <br />10. #of Employees: 1400 Tl. #of Employees Eligible for Plan Participation: $ <br />12. #of Employees Eligible to Receive Medical Benefits upon plan implementation: 12 <br />Plan Implementation 13. (611) Contribution Information: (Note:* = default) <br />Information a, Frequency: (check one): ❑ (0) Biweekly* ❑ (4) Monthly ❑ (8) Semi -quarterly <br />❑ (1) Weekly 0 (5) Semi -Monthly ❑ (9) Bi-annually <br />❑ (2) Semi -weekly ❑ (6) Bi-quarterly ❑ (10) Annually <br />❑ (3) Bi-monthly ❑ (7) Quarterly ❑ (11) Semi-annually <br />❑ ( ) Other: <br />b. Deposit Medium: (624) ❑ Chock * ® Wire 0 EFT <br />c. Data Medium: EZLmk Required to participate in RHS Plan <br />d. First Contribution Date Fallowing Implementation: 02/20/2015 <br />