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C. Assign mcnr of benefits is no[ permitted. Benefits 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 of reimbursement to the Employer or insurance <br />provider (as allowed by the claims administrator). <br />D. An eligible dependent is (a) the Participant's lawhil spouse, (b) the Parricipant:s child under the age of27. as dfi, <br />by IRC Section 152(f)(1) and Interna( Revenue Service Notice 2010-33, or (e) arty other individual who is a person rn <br />described in IRC Section 152(x), as clarified by internal Revenue Servicc Notice 2004-79. <br />E. -Ihe 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 VantageCare Retirement Health <br />Savings Plan Employer Manual. <br />XIII. Employer Acknowledgements <br />A. The Employer hereby acknowledges it understands that failure to properly fill our this Employer Van[agcCarc <br />Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the -frust and/or loss <br />of rax -deferred status for Employer contributions. <br />B, Q Checl:_this box ifyou are including supporting documents that include plan provisions. <br />By: IFn!7�( R'E <br />By: �JJ// Date: <br />Title: City Manager <br />Clerk of the Council <br />FEB 0 5 2015 <br />Accepted: VANTAGEPOINTTRANSFER AGENTS, LLC APPROVED AS TO FORM <br />!� t,•t LISA E. STORCK <br />L d L.W`i%y Assistant City Attorney <br />g <br />Assistant ecretary, ICMA-RC <br />25E-104 <br />ATTEST: <br />It[f'y//�' ^^/ <br />MARIAD HUIZA <br />C( ERK OF THE COUNCIL <br />FEB 0 5 2015 <br />�0 <br />