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EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS( PLAN ADOPTION AGREEMENT Plan Number: 8 03551 Sclect as appliablr. ❑ Srandalone RHS ❑ lntegmted RHS ❑ Amendment to Existing Plan [Z] Nesv Plan (sec NOTE below) NOTE: (For existing employers only): Check here Q if you want ICViA-RC to use existing plan contact information for this nesv plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. 11.31 along with the adoption materials. Employer Retirement Health Savings Plan Name. I. Employer Name: Cityof Santa Ana Stat, California 11. The Employer herebyattests that it is a unit of a state 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: 01/2012015 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the followingwelfare benefit Plan(s) established by the Employer. cyGsania nna metaee wesare ea+efiu roan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups Tlae following group or groups of Employees arc eligible to participate in she VantagcCarc Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full --•lime Employees ❑ Non -Union Employees ❑ Public Safety Employees— Police ❑ Public Safety Employees— Firefighters ❑ General Employees ❑ Collectively-Ilargained Employees (Specify unit(s)) ® Other (specify group(s)) Clerk of the Council, Chief of Police and Unrepresented Executive Management 'lhe Employee group(s) specified must correspond to a gmup(s) of the same designation that is defined in the starutes, ordinances, rules, reGulations, personnel manuals or other documents or provisions in effect in the stare or locality of the Employer. B. Participation Alandatoty Participation: All Employees in the covered group(s) arc required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employers underlying welfare benclic plan at funding under this \':uuageCl re Re[irca nt Hcalth Savings Plan is in whale or Pasta non-collcetively bargained. self•incured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Swinn 10500 [rill apply. Hese rules may impose taxation on the benefits received by highly compennred individuals ifthe PLm diseriminans in !carat of highly cmnprns;med individuals iu terms oFcligibilicyor benefi�s.'[be Emplpyct zbonld discuss [hese rules with appropriate counsel. C. Participant Eligibility Requirements I. Minimum service The minimum period of service required for participarion is N/A (write NIA if no minimum service is required). 2. Minimum age: •Ilne minimum age required for eligibility to participate is NIA (avrire NA if no minimum age is required). �. 25E-99