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C. Assignment of benefits is not permitted. Benefits will be paid only In the Ilarricipanr, Itisther Survivors, the <br />Employer, or an insurance provider (as allowed by the claims administrator). payments to an third -parry payee <br />(e.g., medical service provider) are not permitted with cite exception of reimbursement to the Employer or insurance <br />provider (as allowed by the claims administrator). <br />D. An eligible dependent is (a) cite Participant's lawful spouse, (b) the Participants child under the age of 27, as definctl <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 Internal Revenue Service Notice 2004-79. <br />E. the Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which <br />am rimmed to be diseriminarory under IRC Section 105(h), as ourlined in cite VancageCare Retirement Health <br />Savings flan Employer Manual. <br />XIII. Employer Acknowledgements <br />A. The Employer hereby acknowledges it understands chat failure to properly fill out this Employer VanageCare <br />Retirement Health Savings Plan Adoption Agreement may result in the loss of ax excnaptian of the Trust and/or loss <br />of tax-deferred status for Employer contributions. <br />B. ❑ Check this box if you are including supporting documents that include plan provisions. <br />EMPLOYER SIGNATURE <br />By:_(y7-l�tnG� 1" l `-� <br />Title, Executive Director, Personnel Services <br />Attest;_"/ / \ 6'iMlL 2- J IV[' f <br />Title: Clerk of the Council <br />Accepted: VA. iTAGEPOINT TRANSFER AGENTS, LLC <br />v..�a� <br />Assistant, ecrerarv, ICNLI RC <br />PPR 0 FORM <br />Jose San o <br />enior Assistant City Attorney <br />Date: �5/aO/ � s <br />Date: 5- <br />Ze2�/r�r%/� <br />CLF.S(K OF E COUNCIL <br />25E-97 <br />