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C. Assignment of benefits is not permitted. Benefus 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 ofreimbursemem 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 Participam's child under the age o €27, as defined <br />by IRC Section 1520(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 VamageCare 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 VamageCare <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 />E. 0 Check this box if you are including supporting documents that include plan provisions. <br />EMPLOYER SIGNATURE <br />By: C Date: /C7 /o2o1 <br />Title: Executive Director, Personnel Services <br />Attest: %'Y 1. �/1"__. /� /Iv i%1 lr'' Date: <br />Trrtd. Clerk of the Council <br />Accepted: VANTAGEPOINT TRANSFER AGENTS, LLC <br />n <br />Assistant ecru nary ICMA -RC 41 <br />LPPR 0 "OR M S1 <br />Jose an o MARI D. HUI <br />enior Assistant City Attorney CLE K OF THE CO C11L <br />a <br />