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C. Assigunnsnt of benefits is not permltrad. Benefits will be paid only to the Participant, his /her Survivors, the <br />Employer, or an insurance provider (as al loved by the claims ado Inistraror). Payments to an till rd -party payee <br />(e.g., medical service provider) are not permitted with rite exception of reimbursement to the Employer or insurance <br />provider (as allowed by the claims administrator). <br />D. An eligible dependent is (a) the Pirricipait t:s lawfitI spouse, (b) die Participants child under the age of 27, as defined <br />by IRC Section 152(0(1) and Ine run I Revenge Sery ice Notice 2910 -38, or (c) any other individual who is a person <br />described in IRC Section 152(x), as clarified by Internal Revenue Service Notice 2004-79. <br />E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes her payments which <br />are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare I2erirenrent ]-Yeah, <br />Savings Plan Employer Manual. <br />X111. Employer Acknowledgements <br />A. Tlie'Employer hereby acknowledges it understands chat failure to properly fill our this Employer VanrageCare <br />Retirement Health Savings Plan Adoption Agreement mar result in the loss of tax exemption of the Trust and /or loss <br />of rnx def rred status for Employer con [ributons. <br />B. 0 Check this box if you are including supporting documents that include plan provisions. <br />EMPLOYERSI <br />B _. Date. <br />'title: City Manager <br />Attest. Date: <br />Clerk of the Council <br />Accepted: VANTAGEPOINTTRANSFERAGENtS, LLC <br />} t <br />)Jf n <br />Assistant ilecretary, tCt41r4RC <br />A TESTO <br />MARIAD. HUrI ZARC �j�CIL <br />CLERK P' u <br />2Q13 <br />APPROVED AS TO FOILAI <br />Laura A. Rossini <br />Senior Assistant CityAttornc•. <br />