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C. Auignnsent rrbeucrits is not pet in Beoefirs will be paid only m the Participant, his/her Survivors, the <br />Employer, c r an insurmce provider (as allowed by the elainu admbtisurnmr). Payments man third -party payee <br />(e.g.. medical service provider) arc nor permiued will, Elie exception of reimbursement in the Employer or insurance <br />provider (as ullowed by the claims adminisrratnd. <br />D. An eligible dependent is (,d the Participants lawful spouse, (h) cite Participanri child tinder rhe age of 27, as dclincd <br />by IRC Section, 152(0(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 Inrermal Revenue Service Notice 2004-T). <br />E. The Employer will he responsible for withholding, reporting and remising any applicable taxes rnr prynscors which <br />are deemed to be diseriminaccry under IRC Section 105(h), as outlined in Elle VSmageGw Retirement Flealth <br />Savings Plan Employer Manual. <br />XIII. Employer Acknowledgements <br />A. The Employer hereby acknowledges it undcrsmnds char failure to properly rill our this Employer VancngeCam <br />Reriremcnc Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Tmsr and/or loss <br />of rax -deferred status for Employer contributions. <br />B. 0 Check this box if you are including supporting documents that include plan provisions. <br />EMPLOYE•RSIGNATURE <br />d <br />By. _ .. �� � Date: 1 '� <br />Title, City 6 nage. <br />Attest• Date: <br />Tide. Clerk of the Council <br />Accepted: VADITAGEPOfNTTRANSFER AGENTS, LLC APPROVED AS TO 17010,1 <br />5>v�iy Laura A. Rossini <br />eLsistanr eeretary, ICNIA-RC <br />Senior Assistant City Attoriw.. <br />M;RIA • 1 ZAR <br />CLERK OF THE COUNCIL <br />DEC D 8 2015 <br />25E-84 <br />