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SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT <br />HEALTH SAVINGS (RHS) PLAN <br />Plan Number: 8 03551 <br />Namc oFlimploycr. City of Santa Ana <br />Affirmative Statement of the above-named Employer (the "Employer"): <br />WHEREAS, the Employer has employees rendering valuable services; and <br />snuc, California <br />WHEREAS, the establishment of a retiree health savings plan serves the interests oFthc Employer by enabling it to provide <br />reasonable security regarding such employees' health needs during retirement. by providing increased flexibility in its <br />personnel management system, and by assisting in the attraction and retention of competent personnel; and <br />WHEREAS, the Employer has determined char the establishment of the retiree health savings plan (the "Plan") serves the <br />above objectives; <br />NOW TH EREFORE, as a duly authorized agent of the Employer, I hereby: <br />ESTABLISH the Employer's Plan in the form of the ICMA Retirement Corporation's VantageCarc Retirement Health <br />Savings program; and <br />SPECIFY than the assets of the Plan shall be held in trust, wirh the following entity or individual serving as trustee (Selecr one): <br />0 the Employer <br />❑ the following position within the Employer. <br />❑ the following group or committee within the Employer. <br />❑ the following rhird-parry trusree: <br />f iwn vtv meind";duat 3vMnp nuaml <br />lie"t;VwPm cw,miun xdvps uw,R7 <br />Gnrnmn¢ar,M,d.ya,m niuue7 <br />for the exclusive benefit of the Plan participants and their survivors, and die assets of the plan shall not be diverted to any other <br />purpose prior to the satisfaction oral) liabilities of the Plan. The Employer has executed the Declaration of <br />vast oFthe City of Santa Ana Integral Part Trust in the form oF. (Selecr one) <br />IZI The model trust made available by the ICMA Retirement Corporation <br />❑ The trust provided by the Employer (executed copy attached hereto). <br />SPECIFYrharthe Personnel Services/Employee Benefits Department shall be the coordinator <br />and contact for the Plan and shall receive neecssery reports, notices, etc <br />DATE: <br />FEB 0 5 2015 <br />ATTEST <br />i�GL�^RlLI�S�r� <br />ARIA D HUIZAR /J <br />CLERK OF THE CO CIL <br />City Manager <br />Tide of Designated Agent <br />Signature <br />25E-98 <br />g5 <br />