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SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT <br />HEALTH SAVINGS (RHS) PLAN <br />Plan Number: 8 03550 <br />Name of Employer: City of Santa Ana <br />State: California <br />Affirmative Statement of the above -named Employer (the "Employer"): <br />WHEREAS, the Employer has employees rendering valuable services; and <br />WHEREAS, the establishment of a retiree health savings plan serves the interests of the Employer by enabling it to provide <br />reasonable security regarding such employees' health needs during retirement, by providing increased flexibility in its <br />personnel management system, and by assisting in the attraction and retention of competent personnel; and <br />WHEREAS, the Employer has determined that the establishment of the retiree health savings plan (the "Plan") serves the <br />above objectives; <br />NOW THEREFORE, as a duly authorized agent of the Employer, I hereby: <br />ESTABLISH. the Employer's Plan in the form of the ICMA Retirement Corporation's VantageCare Retirement Health <br />Savings program; and <br />SPECIFY that the assets of the Plan shall be held in trust, with the following entity or individual serving as trustee (Select one): <br />91 the Employer <br />❑ the following position within the Employee <br />❑ the following group or committee within the Employer: <br />❑ the following third -party trustee: <br />( Inscn ddcdim hvid-1 naing. ", '.) <br />aw.... ... , u, min,ntrmc "t.." ae aumc) <br />(Insert n,m of 66d-pn., au ... c) <br />for the exclusive benefit of the Plan participants and their survivors, and the assets of the plan shall not be diverted to any other <br />purpose prior to the satisfaction of all liabilities of the Plan. The Employer has executed the Declaration of <br />trust of the City of Santa Ana _ Integral Part Trust in the form of: (Select one) <br />la The model trust made available by the ICMA Retirement Corporation <br />❑ The trust provided by the Employer (executed copy attached hereto). <br />SPECIFYthatthe Personnel Services/Employee Benefits Department <br />and contact for the Plan and shall receive necessary reports, notices, etc. <br />DATE: <br />shall be the coordinator <br />Executive Director, Personnel Services <br />Title of Designated Agent <br />Signature <br />