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A-2011-258-02 IL oVZ)VNANCE EXPIRES 1-15 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN IH1 F1. ,,i ADOPTION AGREEMENT Plan Number: 3 03237 Select as applicable: ❑ Stvtdalonc RHS ❑ Integrated RHS 0 Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers.only): Check here [2) if you want 1CMA-RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return chi: Implementation. Data Form found on pg. II:31 along with the adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana State: CA 11. The Employer hereby attests that it is a unit of astate 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: Odlober 1, 2014 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 ofSanta Ana RettreeWellareBenefiitsPlan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VamageCare Retirement.Healdh 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 ❑ Collectively -Bargained Employees (Specify unit(s)) Police Management Association, Fire Management Association, Other (specify gmup(s)) Collectively -Bargained Employees continued: Santa Ana Management Association & Confidential Association of the City of Santa Ana 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 du Employer. B. Participation klandatory Participation: All Employees in the covered group(s) are required m participate in the Plan and shall receive contributions pursuant to Section VI. If the F.mploycr's underlying welfare benefirplan br.,funding.under Ellis VaittageCare Retirement Health Savings Plari4s iti ; i- whole or pa,'rt a non -collectively bargained self insured pla vthe nondiscrimination requirements of Internal Revenue (IRC) Section 105(h) hilt apply. These: rules may impose taxation on the benefiii;rec&t ed by highly compensated mdtytduals if the Plandncnmmates'infavor ofhighly compensated individuals in terms ofeligihility or benefits fhhc Employer should discuss these rides with appropriate counsel. C. Participant Eligibility Requirements I. Minimum service: -Ilse minimum period of service required for participation is N/A (write NIA if no minimum service isrequired). 2. Minimum age: -lie minimum age required fur eligibility to participate is NIA (write NIA if no minimum age is required).----