INTERNATIONAL CITY MANAGEMENT ASSOCIATION RETIREMENT CORPORATION (ICMA) (CITY MANAGER) 1E

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�J 1C v� s V� 5 C'J i A �i A- 2015 - 023 -01 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RH5) PLAN ADOPTION AGREEMENT Plan Number: S 03550 Select as applicable: ❑ Standalone RHS ❑ bitegrateci RHS K Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers only): Check here Z if you want ICMA -RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. 11:31 alongwith the adoption materials. Employer Retirement Health Savings Plan Name:: 1. Employer Name: City of Santa Ana State: California 1I. The Employer hereby attests that it is aunt of a state or local government or an agency or instrumentality of one or more units of a state or local government. 11I. Effective Date of the Plan: 06/01/2015 IV The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: CRY of saotaAna Rati:aewerare aeneats elan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups. of Employees are eligible to participate in the UantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ Ali Full -Time Employees ❑. Non - Union. Employees ❑ Public Safety Employees:- Police ❑ Public .Safew Employees — Firefighters ❑ General Employees ❑ Collectively-Bargalned Employees (Specify unit(s)) ❑ Other (specify group(,)) City Manager the Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals e or other documents or provisions in effect in the state or locality of the Employer. S. Participation Mandatory Participation., All Employees in the covered group(s) are required to participate in die Plan and shall receive contributions pursuant to Section VL If the Employer's underlying welfare benefit plan or feuding under this UantageCare Retirement Health Savings Plan is in -- whole or part a non collectively bargained, self- insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan disc, iminares in favor of highly compensated individuals in terms ofel'igibilay or benefits. The Employer should discuss these rules with appropriate counsel C. Participant Eligibility Requirements I. Minimum service: The minimum period of service required for participation is N/A (write N/A it no minimum service is required). 2. Minimum. age: The minimum age required for eligibility to participate is N/A (write N/A if no minimum age is required).