AGR-6561.1 - CITY OF ORANGE - OMA - VANTAGECARE RETIREMENT HEALTH SAVINGS ADOPTION AGREEMENTAQ4.s ro 1. I
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RETIREMENT HEALTH SAVINGS (RHS)
ADOPTION AGREEMENT
VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS)
ADOPTION AGREEMENT
Plan Number. S 03741
Sclect as applicable: QStwdalone RHS Inmgmted RHS s Amendment m Existing Plea
I. Employer Names City of Orange Staten. CA
II. The Employer hembyattews that iris aunitofasrate orlocal government oran agenryorinstramentalityofam or
more units of a state or local government.
IIL Plan Dates
A. PhuAmmdmentFHecdveDam 1/1l2020
B. Plan Vean Enter the annual accounting period for the RHS program. 1/1 -12/31
IV. The Employer intends to utilize the Trtutm fend onlywelfxre benefits pursuant to the following welfare benefit
plaa(s) esmbliahed by the EmplayetModel Welfare Plan V.
Eligible Groups, Participation and ParticipantEligibllityRegairements A.
Eligible Groups The
following group or groups of Employees are eligible to participate in the Employer's welfare benefits plan identified in
Swdm IV. (check all applicable boxes): All
Employees All
Full -Tune Employers Non -
Union Employers Public
Safety Employees —Police Public
Safety Employers — Firefighters Cenral
Employees Collectively -
Bargained Employees (Specify mtit(s)) See Attached Other (
specify group(s)) The
Employee grmup(s) specified must correspond to agmup(s) of the same designation that is defined in the statutes, ordinances,
rules, regulations, personnel manuals or other documents or provisions in effect In the state or locality of the
Employer. B.
Participation N4nduory1lardeipatioru
All Employees in the covered group(s) are required to participate in the
Plan and shall receive contributions pursuant in Section VI. If
the Employer's underlyingwelfare benefit plan is in whole or put a non -collectively bargained plan that allows reimbursement
for medical espeoses other than insurance premiums, the nondiscrimination requirements of Internal
Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by
highly compensated individuals If the Plan discriminates in favor of highly compensated individuals in terms of eligibility
or benefits. The Employer should discuss these rules with appropriate counsel.
C. Participant Eligibility Requirements
I. Minimum service:'ILe minimum period ofservice required for participation is N/A (write N/A if no minimum
service is required).
2. Minimum age: The minimum age required for eligibility to participate is Nip (write N/A if no minimum age is
required).
VL Contribution Sources and Amounts
A. Definition of Earnings
The definition of Earnings will apply to all RHS Contribution Features that reference "Earnings", including Direct
Employer Contributions (Section VI.B.1) and Mandatory Employee Compensation Contributions (Section VI.B.2.).
Definition of earniagr.
B. DirectEmployer Contributions and Mandatory Contributions
I. Direct Employer Contributions
The Employer shall contribute on behalf ofeach participant
of Earnings"
each Plan Ycm
A discretionaryamount ro be dacrmincd cach Plan Ycar Other (
describe): 2.
Mandatory Employee Compensation Contributions The
Employer will make mandatory contributions of Employee compensation as follows: Reducxion
in Salary- % of Earnings m $ will be contributed for the Plan Year. Decreased
Merit or Pay Plan Adjustment -All or a portion of the Employees annual malt or
pay plan adjustment will be contributed as follows: An
Employee shall noihave the right to discontinue or vary the rate of Mandatory Contributions of Employee Compensation. .
3.
Mandatory Employee Leave Contributions The
Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory
Employee Leave contributions): Q
Accrued Sick Leave 100% of eliaible cash out value Upon
retirement from City Accmed
Vacation Leave Other (
specify type of leave) Accrued F_ Leave Floating
Holidays -see attached An
Employee shall nor have the tight to discontinue orvary the ram of mandatory leave contributions. Non-
rolkctivrly bargained plantthat nimburre mrdira[eapenresothn than inruranrepremiumt should tumult their benefro roronel regarding
welfareplan nwrdiscrimbration ruler iftbe employer elects to make contribution; bared on a pnrentagtofearningt.
C. Limits on Total Contributions (check one box)
The total contribution by the Employer on behalf of each Participant (including Direct Employs and Mandatory
Employee Contributions) for each Plan Yw shall not exceed the following linah(s) below. Limits on Individual
contribution types are defined within the appropriate section above.
r There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed.
ofcarnings
Definition of earnings: Same as Section VLA. Otha
for the Plan year.
VII. Vesting for Direr Employer Contributions
A. Vesting Schedule (check one boa)
The account is 100% vested at ali times.
The following voting schedule shall apply to Direct Employer Contributions at outlined in Section VLB.1:
Years of So rice Vesting
Completed Percentage
B. The account will become 1000/6vested upon the dead, disability, retirement•, or attainment of benefit
eligibility (as outlined in Section M by a Participant.
Definition of retirement includes a separation from service component and is further defined by (check one):
The primary retirement plan of the Employer
Separation from service
Other
C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall not count
toward the vesting schedule outlined in A above.
VIIL Forfeiture Provisions
If a Participant separates from service prior to full vesting, non -voted funds in the Participants account shall be forfeited in
accordance with the box checked under this section.
Upon the death of a participant, surviving spouse, and all surviving eligible dependents (as outlined in Section XI), funds
remaining in the Participant's account shall be avert to the Trust in accordance with the box checked under this section.
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B. No Surviving SpamearSurviving Dependmn
If them arc no living spouse or dependents a the time of death of the Participant, the account will revert in accordance
with the Employer's election under Section Vill of the VantageCare RHSAdoption Agrerment. XII.
The Plan will operate according to the following provisions: A.
Employer Responsibilities 1.
The Employer will submit all VantageCare Retirement Health Savings Plan contribution dare via electronic submission. 2.
The Employer will submit aB V=mgeCare Retirement Health Savings Plan Participant am= updates or personal information
updates via electronic submission. Ibis includes but Is not limited to termination notification, benefit eligibility,
and vesting noefication. B.
Participant account administration and asset -based fees will be paid through the redemption of Participant account shares,
unless agreed upon otherwise in the Administrative Services Agreement. C.
Assignment of benefits is not permitted. Benefits will be paid only to the Participant, his/her Survivors, the Employer,
or a s insurance provider (as allowed by the claims administrator). Paymenra to a third -party pays (e.g.. medical
service provider) are not permitted with the atception of reimbursement to the Employer or insurance provides (
as allowed by the claims administrator). D.
An eligible dependent is (a) the Parricpant s lawful spouse, (b) the Parricipanes child under the age of27, as defined by
IRC Section 152(f)(1) and Internal Revenue Service Notice 2010-38. or (c) any other individual who is a person described
in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004-79. E. '
Ihe Employer will be responsible for withholding, repotting and remitting any applicable taxes for payments which we
deemed to be discriminatory under IRC Section 105(h), as outlined in the VanragrC.arrRedrement Heahh Savings Employer
Manual. XIII.
Employer Acknowledgements A.
The Employer hereby acknowledges it understands that failure to properly 511 out this YanrageCne RdiremeatHwIth SavingsAdoptionAgsemnent
may result in the loss of tar exemption of the Trust and/or loss of rax-deferred stars for Employer
contributions. B.
21 Check this box if you are including supporting documents that include plan provisions. EMPLOYER
SIG Due:
n,
j., City Clerk