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tai; QAAPK,P pPl FIL 6_ WORK MAY PROCEED UNT L iHSIJRANCE EXPIRE, 1%-2011-258-02 CLERK OF COUNCII DTE EMPLOYER VANTAGECARE RETIREMENT -HEALTH- SAVINGS (RHS( PLAN ADOPTION AGREEMENT Plan Number: 8 03237 Select as applicable: ❑ Standalone RHS ❑ Integmred RHS El Amendment to Existing Plan ❑ New Plan (see NOTE bclmv) NOTE: (For existing employers only): Check here p if you want [CMA -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 along with the adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana Scare: CA 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. III. 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 or Santa Arta Retiree Wetton aenofts Flan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VanrageCare Retirement Health Savings Pian (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively -Bargained Employees (Specify unic(s)) Police Management Association, Santa Ana Management Association, m Other (specify group(s)) Confiden0al Association of the City of Santa Ana 8 Full Time and Pan Time Civil Service Employees recognized by the Santa Ana City Employees, Chapter 1939/Service Employees international Union Loral 721 (SEIU) The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statures, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation Alan canny Participation. tVI 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 underlyingwelfare benefit plan or funding tinder this Vantage Care Retirement Health Savings Plan is in whole or pan 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 tire 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 rules with appropriate counsel. C. Participant Eligibility Requirements 1. Nlinimum service: The minimum period of service required for participation is NIA minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is N/A age is required). > EXHIBIT H e 25E-79 (write N/A if no (write N/A IF no minimum