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A-201 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number. 8 03550 Select as applicable. ❑ Standalone RHS ❑ Iniegrand RHS [D Amendment m Existing Plan ❑ New Plan (.see NOTE below) NOTE: (For existing employers only): Check here © ifyou s¢u¢ ICNIA-RC to use esisring 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 die adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana State: California Il. The Employer hereby attests that it is a unit oFa state or loaf government or an agency or instrumentalityof one or more units ofa state or local government. III. Effective Date ofthe Plans 061012015 N. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: Ceyor Sam.Ana Reseaweiremae,cM4P6 V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employeks are eligible to participate in die VantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safcty Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively-Bargai=1 Employees (Specify unit(s)) 0 Other (spccifv group(s)) City Manager Tyre Employee group(s) specified mttsc correspond m 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 clue irate or locality of the Employer. B. Participation Alandatoty Partieipatiom NI Employees in die covered group(s) are required to participare in rite Plan and shall receive contributions pursuant to Section VI. If elm Employes underlyingwelfare benefit plan or Funding under this V.tnrageCare Retirement Hcsleh Savings Plan is in whole or pan a non -collectively bargained, self-insured plan, the mndiscriminarion requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules mry impose taxation on the benefits received by highiymmpensared individuals if the Plan diserindjura in favor of highly coinpemarcd individuals in terms oFeligibility or henefin. The Employer should discuss these rtes with appropriate counsel. C. Participant Eligibility Requirements 1. Minimttnt service: The minimum period oFservice required for participation is NIA (write NIA if no minimum service is required). ?. Nliuinmm age: The miriinmm Age required for c[i 6iili[y to participate is (scalae \4:1 Wan minimum age is required). , t . 25E-92 N