ICMA-RC VANTAGECARE (RHS PLAN) 1F

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h'df1MANICi =. M FII_t WORK MAY PROCEED UNTIL INSURANCE EXPIRE A- 2011- 258 -03 DATE. z 15 OUNC'EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number: S 03237 s� Q1 Select as applicable: ❑ Standalone RHS ❑ Integrated RHS El Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers only): Check here © 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. II:31 along with the adoption materials. Employer Retirement Health Savings Plan Name: I. Employer Name: City of Santa Ana State: CA d II. The Employer hereby attests that it is a unit 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: 01/01/2016 $ 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: city of Santa Ana Retiree welfare SeneSts Plan - o V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups 'the following group or groups of Employees are eligible to participate in the VantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees K Collectively- Bargained Employees (Specify unit(s)) Police Management Association, Santa Ana Management Association, V1 Oilier (specify group(s)) Confidential Association of the City of Santa Ana & Full Time and Part Time Civil Service Employees recognized by the Santa Ana City Employees, Chapter 1939 /Service Employees International Union Local 721 (SEIU) 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 or other documents or provisions in effect in the state or locality of the Employer. B. Participation Mandatory Participation: All Employees in the covered group(s) are required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan is in whole of 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 discriminates in favor of highly compensated individuals in terms of eligibility or benefits. The Employer should discuss these mules with appropriate counsel. C. Participant Eligibility Requirements 1.. Minimum service: -the minimum period of service required for participation is N/A (write N/A if 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).