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C. Assignment of benefirs is not 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) arc 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 lawful spouse, (b) the Panicipanc s child under the age of 27, as defined <br />by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010.38, or (c) any other individual who is a person <br />described in IRC Seecion 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 (axes for payments which <br />arc 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 out this Employer VantageCare <br />Rciircment Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and/or loss <br />of tax-deferred status for Employer contributions. <br />Be ® Cheek this box if you arc including supporting documents that include plan provisions. <br />EMPLOYEFSIG PLE L / <br />By:, <br />O,/) /- i/iy�tY/ <br />Tyler City Manager r ^ <br />Attest; <br />Clerk of the Council <br />Acccptcd: VANTAGEPOINT TR/uNSFER AGENTS, LLC <br />t <br />z <br />Assistant gecrctary, ICvul-RC <br />Date: <br />Date: <br />25E-91 <br />A,PT , "0 AST FO <br />RIM <br />/ Joseph Straka <br />Assistant City Attorney <br />