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HomeMy WebLinkAboutRESOLUTION - 43-04 - 10/26/2004 - AMEND RES NO 22-02RESOLUTION NO. 43-04 A RESOLUTION AMENDING RESOLUTION NO. 22-02 A VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN OF THE VILLAGE OF ELK GROVE VILLAGE QCMAI WHEREAS, the Employer, the Village of Elk Grove Village, has employees rendering valuable services; and WHEREAS, the Employer, the Village of Elk Grove Village, has established a retiree health savings plan in the form of the VantageCare Retirement Health Savings Plan (the "Plan") for such employees that serves the interest of the Employer by enabling it to provide reasonable security regarding such employees' health needs during retirement, by providing increased flexibility in its personnel management system, and by assisting in the attraction and retention of competent personnel; and WHEREAS, the Employer, the Village of Elk Grove Village, has determined that the continuance of the Plan serves the above objectives. NOW, THEREFORE, BE IT RESOLVED by the Mayor and Board of Trustees of the Village of Elk Grove Village, Counties of Cook and DuPage, Illinois: Section 1. That the Employer, the Village of Elk Grove Village, hereby amends and restates the Plan as outlined in the attached Declaration of Amendment to the VantageCare Retirement Health Saving Plan; and Section 2. That the assets of the Plan shall be held in trust, with the Employer, Village of Elk Grove Village, as Trustee ("Trustee") for the exclusive benefit of Plan participants and their beneficiaries; and Section 3. That the assets of the Plan shall not be diverted to any other purpose prior to the satisfaction of all liabilities of the Plan; and Section 4. That the Employer, the Village of Elk Grove Village, executes the Declaration of Trust of the Village of Elk Grove Village Integral Part Trust in the form of the model integral part trust agreement made available by the ICMA Retirement Corporation. Section 5. That this Resolution shall be in full force and effect from and after its passage and approval according to law. VOTE: AYES: 6 NAYS: 0 ABSENT: 0 PASSED this 26th day of October, 2004. APPROVED this 26th day of October, 2004. ATTEST: Ann I. Walsh Village Clerk ResRetirementHeelthAmend.doc Fj APPROVED: Mayor Craig B. Johnson Village of Elk Grove Village ATTACHMENT C DECLARATION OF AMENDMENT TO THE VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN Plan Number: 8-0 Q H 0 3 Name of Employer: V;LLA6E of ELY- GROVE ) LLAT State: MLttrJui S The Employer is amending its VantageCare Retirement Health Savings (RHS) Plan to incorporate the provisions selected below. Section numbers refer to the appropriate section of the VantageCare RHS Adoption Agreement. Part I• Addition of New Participation and Contribution Features: Complete Part I if you wish to add the new participation and/or contribution features to your RHS plan. Effective Date: ZAiJaA1.Y 1. 10b (insert effective date of amendment). V. Eligible Groups and Participant Eligibility Requirements Use this section to allow your employees to choose to participate in the RHS program. If you do not select this option, participation will continue to be mandatory for the employee group(s) named in your original RHS Adoption Agreement. If you .choose this option, employees that do not opt to participate in RHS will not receive mandatory contributions or be allowed to choose to make elective employee contributions (see SectionVI). Irrevocable Election to Participate Q If this box is checked, in lieu of mandatory participation, the Employer provides for a one-time irrevocable election by eligible Employees to participate in RHS. Until such time as the election is made, the Employee shall not participate in the Plan or receive contributions pursuant to section VI of the RHS Adoption Agreement. Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of initial eligibility during which they may make the election to participate. Participation may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to partici- pate may be made in a later year. An annual election window of days (no more than 60 calendar days) shall be provided during which the election may be made.The election win- dow shall run from to (insert your annual time frame for the election win- dow,; e.g. October 1 to November 29). Participation may begin no earlier than the calendar year fol- lowing the year of the election. Once made, the election is irrevocable and may not be revoked while the participant is a member of the group covered by the RHS plan. Plan Number: 8 6 Q i ! Existing RHS participants If you have chosen to allow your employees to elect to participate in RHS, you must choose one option below with respect to existing participants. Existing RHS Participants shall be allowed to revoke their participation in the Plan on a one-time irrevocable basis. Participants shall be provided a 60 calendar day window from the effective date of the plan amenchnent to revoke participation. Revocation shall be made on a form provided by the ICMA Retirement Corporation and returned to the Employer. Once participation is revoked, the Participant may not elect to participate in the Plan at any later time. Account assets of Participants that revoke participation shall remain in the Trust to be distributed under the terms of the PIan as outlined in the Employees VantageCare RHS Adoption Agreement. Existing RHS Participants shall not be allowed to revoke their participation in the Plan. By adopting the elective participation option, the Employer acknowledges that the Internal Revenue Service has not ruled on an irrevocable election to participate in an integral part trust. ICMA-RC has obtained the advice of counsel that such an election is allowable under the conditions outlined in this Adoption Agreement. The Employer should discuss this issue with appropriate counsel. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan, is in whole or part, a non -collectively bargained, self-insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxa- tion on the benefits received by highly compensated Employees if the Plan discriminates in favor of highly compensated Employees in terms of eligibility or benefits. The Employer should discuss these rules with appropriate counsel. VI. Contribution Sources and Amounts Use sections A and/or B to define your contribution formula(s) for your RHS plan. Section C defines your overall plan contribution maximum (if any). Check the boxes that apply, and complete your fund- ing formula(s). A. Mandatory Contributions 0 1, Direct Employer Contributions: The Employer shall contribute on behalf of each Participant of earnings or S for the Plan Year. Definition of earnings: )9A)AIWIL ARSE S'ALAP_Sj - I Plan Number: 8D L LL Q 2. Mandatory Leave Contributions: The Employer will make mandatory contributions of leave as follows: Accrued Sick Leave* IR3 Yes 173 No Accrued Vacation* 0 Yes 171 No Other (describe)* C3 Yes No * Please provide the formula for determining the accrued leave An Employee shall not have the right to discontinue or vary the rate of mandatory leave contribu- tions. [� 3. Mandatory Employee Compensation Contributions: The Employer will make mandatory contributions of Employee compensation as follows: Reduction in Salary - % of earnings (as defined in VI.A.I.) or $ will be contributed for the PlanYear. Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of mandatory contributions of Employee compensation. B. Elective Contributions: If you wish to provide for elective contributions, complete sections 1 and/or 2 as appropriate. 1. The Employer will permit each Employee to make the following elections to make pre-tax contri- butions to the Plan: r3a. Irrevocable Election for Pre -Tax Contributions from Compensation: A one-time, irrevocable election of the amount of Employer contributions of compensation made on his or her behalf. Plan Number: 8Q Q -q- Q 3 - The Employer limits the amount elected to either a fixed percentage or a range of percentages of an Employee's earnings (as shown below): SAID JQa% 06 MEPop LO.J6'Evjry ��3,5 ], % of earnings (as defined in VI:A.1.) moi__ v a c_cam`c:�' cz� I�JH/GHEi/EPcIES. Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window ofdays (no more than 60 calendar days) sh ll be provided during which the election may be made. The election window shall run from to AIZ4/ (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. Ob. Irrevocable Election for Pre -Tax Contributions of Accrued Leave: A one-time, irrevocable election of the amount of Employer contributions of accrued sick M vacation other {describe) leave made on his or her behalf. The Employer limits the amount elected as shown below: Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window of.. Yj�_days (no more than 60 calendar days) shall be provided uring which the election may be made.The election window shall run from J j to XF'Cf/9dZ.1 /5- (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. ita Plan Number: 8 O D. 10 3- M Q3- Mc. Annual Prospective Election for Pre -Tax Contributions of Leave: An annual, irrevocable elec- tion to have his or her 0 sick 0 vacation X1 other (describe) leave to be accrued in the next calendar year, contributed to the Plan on his o her behalf. /. /'� 2, 3 012 1% 09Y% Contributions of future leave accruals will be remitted to the Plan of F&AiM& HdJ,0 2, ✓ALUC OF AAW CPA as earned Q at the end of the calendar year 7_1WE CAtW60. The,elecpQn,tq,contribute must be made in the calendar year before the year in which contributions are to begin. Once made, the election shall apply to succeeding calendar years unless otherwise revised or revoked by the Employee on an annual basis. An. annual election window of 44b days (no more than 60 calendar days) is provided during whi h eligible Emyp�loyees may make the election to contribute. The election window shall ,run from 2AJ 1 to U&CFHA£R %'5' of the year prior to the year contributions of leave will begin (insert your annual -time frame for the election window). The Employer limits the amount elected as shown below: In adopting section a, b, and/or c, the Employer acknowledges that the Internal Revenue Service has not ruled on irrevocable election contributions in an integral part trust. ICMA-RC has obtained the advice of counsel that such contributions are allowable under the conditions outlined in this Adoption Agreement. The Employer should discuss this issue with appropriate counsel. 0 2. Voluntary After -Tax Contributions: Each Employee may contribute up to % of earnings (as defined inVI.A.l.) or; for the P1anYear on a voluntary after-tax basis. In no event may aggregate Employee voluntary after-tax contributions exceed 25% of total contri- butions in any P1anYear. An Employee shall have the right to discontinue or vary the rate of voluntary after-tax contributions of Employee earnings. In adopting this section, the Employer acknowledges that the Internal Revenue Service has declined to rule on Employee after-tax contributions in an integral part trust. ICMA-RC has obtained the advice of counsel that such contributions are allowable in an insubstantial amount (i.e. no more than 25% of total contributions in any P1anYear).The Employer should discuss this issue with appropriate counsel. C. Limits on Contributions: Use this section to define your overall maximum contributions for all contribution types you selected. (Limits on individual contribution types are defined within the appropriate sections above.) 11 Plan Number: 8 b Q 4 0 3 The total contribution on behalf of each Participant (including both Mandatory and Elective Contributions) for each P1anYear shall not exceed the following limit(s)- 0 % of earnings (as defined in VI.A.I.). W 19 There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. Part II: Revision of Existing Distribution Features You mut complete Part II to incorporate the HRA -required changes into your existing RHS Plan. These changes udll be effective immediately. Affected provisions include: ✓ Long-term care expenses are no longer a qualifying medical expense (see X.) ✓ Death benefits (see XI, and VIII.) ✓ Severance provision (see XII.) ✓ De minimis provision (see XIII. G.) VIII. Forfeiture Provisions: Complete SectionVlll. if 1) you did not select a forfeiture provision for your existing plan (e.g. because vesting does not apply to your plan) or 2) you wish to change your existing forfeiture selection. Upon separation from the service with the Employer, or upon reversion to the Trust of a Participant's account assets remaining upon the Participant's death (as outlined in Section XI.), a Participant's funds shall: Remain in the Trust to be reallocated among all Plan Participants as Direct Employer Contributions for the next and succeeding contribution cycles(s). Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. Revert to the Employer. In the case of separation from service, the Participant's non -vested funds shall be applied as shown above. In the case of reversion due to the Participant's death, the remaining account assets shall be applied as shown above. X. Permissible Medical Benefit Payments Long Term Care Benefits are not eligible for payment under the Plan. 12 Plan Number: 8 d C)' O 5- X1. Death Benefit In the event of a Participant's death, the following shall apply: Account Transfer: The surviving spouse and/or surviving eligible dependents (as defined in Section XIILF) of the deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. Upon, notification of a Participant's death, the Participant's account balance will be transferred into the Vantagepoint Money Market Fund*. The account balance may be reallocated by the surviving spouse or dependents. * Please read the current prospectus carefully prior to investing. An investment in this fund is neither insured nor guaranteed and there can be no assurance that the Fund will be able to maintain a stable net asset value of $1.00 per share. Vantagepoint Mutual Funds are distributed by ICMA-RC Services, LLC, a controlled affiliate of ICMA Retirement Corporation. Member NASD/SIPC. If a Participant's account -balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible. dependents, the balance will be available for medical benefits for the designated beneficiary of the last dependent or spouse to die. Assets remaining upon the death of a designated beneficiary shall be available for medical benefits of the beneficiary's designated beneficiary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in Section VIII. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's spouse's or dependent's designated beneficiary(ies). If there are no living spouse or dependents at the time of death of the Participant, the account will be available for medical benefits for the designated beneficiary(ies) of the Participant. Assets remaining upon the death of all designated beneficiaries shall be available for medical benefits of the beneficiary's benefi- ciary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in SectionVill. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's beneficiary(ies) or any beneficiary's beneficiary. XII. Termination Prior to Benefit Eligibility This section replaces the Severance Feature previously included in Section XII. In the case of a Participant's termination of employment in advance of retirement (as defined in Section VII.C.) or prior to becoming eligible for medical benefits under the plan (as defined in Section IX.), the 13 Plan Number: 8 O Q�L O a vested value of the Participant's account will be available for benefits: IN Immediately upon termination of employment. 0 As outlined in Section IX. C3 At age XIII.G. Upon termination of employment prior to a Participant becoming eligible for medical benefits from a VantageCare Retirement Health Savings Plan account, Participant accounts that are considered de minimis as specified below will be paid to the Participant. 0 The de minimus account value shall be $5,000 or less. 0 The de minimis account value shall be E (insert dollar amount between $0 and $5,000) or less. The Plan shall not allow de minimis account distributions. EMPLOYER rWW WRIA ���lG�. Accepted: Vantagepoint Transfer Agents, LLC Corporate Treasurer 14 ATTACHMENT C DECLARATION OF AMENDMENT TO THE VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN Plan Number: 80.0 '1 G q Name of Employer: Vi Ll,irse aF ELte GeauE 1/,L 4cE State: _r/,6AI0iz The Employer is amending its VantageCare Retirement Health Savings (RHS) Plan to incorporate the provisions selecfted below. Section numbers refer to the appropriate section of the VantageCare RHS Adoption Agreement. Part I• Addition of New Participation and Contribution Features: Complete Part 1 if you wish to add the new participation and/or contribution features to your RHS plan. Effective Date: JANWA RY 11, 20015' (insert effective date of amendment). V. Eligible Groups and Participant Eligibility Requirements Use this section to allow your employees to choose to participate in the RHS program. If you do not select this option, participation will continue to be mandatory for the employee group(s) named in your original RHS Adoption Agreement. If you choose this option, employees that do not opt to participate in RHS will not receive mandatory contributions or be allowed to choose to make elective employee contributions (see SectionVI). Irrevocable Election to Participate C3 If this box is checked, in lieu of mandatory participation, the Employer provides for a one-time irrevocable election by eligible Employees to participate in RHS. Until such time as the election is made, the Employee shall not participate in the Plan or receive contributions pursuant to section VI of the RHS Adoption Agreement. Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of initial eligibility during which they may make the election to participate. Participation may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to partici- pate may be made in a later year. An annual election window of days (no more than 60 calendar days) shall be provided during which the election may be made. The election win- dow shall run from to (insert your annual time frame for the election win- dow„e.g. October 1 to November 29). Participation may begin no earlier than the calendar year fol- lowing the year of the election. Once made, the election is irrevocable and may not be revoked while the participant is a member of the group covered by the RHS plan. Plan Number: 8 0 0 y O '-� Existing RHS participants If you have chosen to allow your employees to elect to participate in RHS, you must choose one option below with respect to existing participants. Existing RHS Participants shall be allowed to revoke their participation in the Plan on a one-time irrevocable basis. Participants shall be provided a 60 calendar day window from the effective date of the plan amendment to revoke participation. Revocation shall be made on a form provided by the ICMA Retirement Corporation and returned to the Employer. Once participation is revoked, the Participant may not elect to participate in the Plan at any later time. Account assets of Participants, that revoke participation shall remain in the Trust to be distributed under the terms of the Plan as outlined in the Employer's VantageCare RHS Adoption Agreement. C3 Existing RHS Participants shall not be allowed to revoke their participation in the Plan. By adopting the elective participation option, the Employer acknowledges that the Internal Revenue Service has not ruled on an irrevocable election to participate in an integral part trust. ICMA-RC has obtained the advice of counsel that such an election is allowable under the conditions outlined in this Adoption Agreement.The Employer should discuss this issue with appropriate counsel. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan, is in whole or part, a non -collectively bargained, self-insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxa- tion on the benefits received by highly compensated Employees if the Plan discriminates in favor of highly compensated Employees in terms of eligibility or benefits. The Employer should discuss these rules with appropriate counsel. VI. Contribution Sources and Amounts Use sections A and/or B to define your contribution formula(s) for your RHS plan. Section C defines your overall plan contribution maximum (if any). Check the boxes that apply, and complete your fund- ing formula(s). A. Mandatory Contributions 1. Direct Employer Contributions: The Employer shall contribute on behalf of each Participant % of earnings or; for the P1anYear. Definition of earnings: AANUAG 6196Ee 57191 -Ar;" Plan Number: SQ a �L 1�)_ q [� 2. Mandatory Leave Contributions: The Employer will make mandatory contributions of leave as follows: Accrued Sick Leave* Yes No Accrued Vacation* Yes ❑ No Other (describe)* C3 Yes No * Please provide the formula for determining the As cf,IRRE.OrLY EXzs:IA) An Employee shall not have the right to discontinue or vary the rate of mandatory leave contribu- tions. 3. Mandatory Employee Compensation Contributions: The Employer will make mandatory contributions of Employee compensation as follows: Reduction in Salary - % of earnings (as defined inVI.A.l.) or $ will be contributed for the Plan Year. Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of mandatory contributions of Employee compensation. B. Elective Contributions: If you wish to provide for elective contributions, complete sections 1 and/or 2 as appropriate. 1. The Employer will permit each Employee to make the following elections to make pre-tax contri- butions to the Plan: a, Irrevocable Election for Pre -Tax Contributions from Compensation: A one-time, irrevocable election of the amount of Employer contributions of compensation made on his or her behalf. 11 9 Plan Number: 80 0- _q 0— Z The Employer limits the amount elected to either a fixed percentage or a range of percentages of an Employee's earnings (as shown below): ' sc .23. S, Aaa 7.5% of earnings (as defined in VI.A.1.) a C d : VI e t vi iiaa, i lair-vrca'�r. a1111cq,--&1 E' A/�L-/E'S' Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window of _days (no more than 60 calendar days) shall be provided during which the election may be made.The election window shall run from_ to /dkn&4 PAC AV (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. b. Irrevocable Election for Pre -Tax Contributions of Accrued L.eave:A one-time, irrevocable election of the amount of Employer contributions of accrued 0 sick X vacation C3 other her behalf. The Employer limits the amounS elected as shown (describe) leave made on his or Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window of _days (no more than 60 calendar days) shall be provided during which the election may be [Wade. The election window shall run from AkLl / to -CEi1BEc 1S (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. 10 Plan Number: 8A IZ �L Q t9c. Annual Prospective Election for Pre -Tax Contributions of Leave: An annual, irrevocable elec- tion to have his or her 0 sick 0 vacation 0 other (describe) leave to be accrued in the next calendar year, contributed to the Plan on his or er behalf. Contributions of future leave accruals will be remitted to the Plan oL LLOATi�o /idL/OJ}Y• 2 , :/i9GuE 0,- 171 A JY Gc% as earned at the end of the calendar year E AeAX PS0, The, election to. contribute must be made in the calendar year before the year in which contributions are to begin. Once made, the election shall apply to succeeding calendar years unless otherwise revised or revoked by the Employee on an annual basis. An annual election window of q1,6 -days (no more than 60 calendar days) is provided during whi h eligible Employees may make the election to contribute. The election window shall run from M91) / to _QFffirAB2 /S of the year prior to the year contributions of leave will begin (insert your annual time frame for the election window). The Employer limits the amount elected as shown below: In adopting section a, b, and/or c, the Employer acknowledges that the Internal Revenue Service has not ruled on irrevocable election contributions in an integral part trust. ICMA-RC has obtained the advice of counsel that such contributions are allowable under the conditions outlined in this Adoption Agreement. The Employer should discuss this issue with appropriate counsel. 2. Voluntary After -Tax Contributions: Each Employee may contribute up to % of earnings (as defined in VI.A.1.) or S for the P1anYear on a voluntary after-tax basis. In no event may aggregate Employee voluntary after-tax contributions exceed 25% of total contri- butions in any Plan Year. An Employee shall have the right to discontinue or vary the rate of voluntary after-tax contributions of Employee earnings. In adopting this section, the Employer acknowledges that the Internal Revenue Service has declined to rule on Employee after-tax contributions in an integral part trust. ICMA-RC has obtained the advice of counsel that such contributions are allowable in an insubstantial amount (i.e. no more than 25% of total contributions in any PlanYear).The Employer should discuss this issue with appropriate counsel. C. Limits on Contributions: Use this section to define your overall maximum contributions for all contribution types you selected. (Limits on individual contribution types are defined within the appropriate sections above.) Plan Number: 80 D_ Y O L The total contribution on behalf of each Participant (including both Mandatory and Elective Contributions) for each Plan Year shall not exceed the following limit(s): C % of earnings (as defined in VLA. 1.). 19 There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. Part II: Revision of Existing Distribution Features You must complete Part H to incorporate the HRA -required changes into your existing RHS Plan. These changes will be effective immediately. Affected provisions include: ✓ Long-term care expenses are no longer a qualifying medical expense (see X.) ✓ Death benefits (see XI. and VIII.) ✓ Severance provision (see XII.) ✓ De minimis provision (see XIII. G.) VIII. Forfeiture Provisions: Complete Section VIII. if 1) you did not select a forfeiture provision for your existing plan (e.g. because vesting does not apply to your plan) or 2) you wish to change your existing forfeiture selection. Upon separation from the service with the Employer, or upon reversion to the Trust of a Participant's account assets remaining upon the Participant's death (as outlined in Section XI.), a Participant's funds shall: ❑ Remain in the Trust to be reallocated among all Plan Participants as Direct Employer Contributions for the next and succeeding contribution cycles(s). IN Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. C3 Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. Revert to the Employer. In the case of separation from service, the Participant's non -vested funds shall be applied as shown above. In the case of reversion due to the Participant's death, the remaining account assets shall be applied as shown above. X. Permissible Medical Benefit Payments Long Term Care Benefits are not eligible for payment under the Plan. 12 t Number: 8_0 d O Death Benefit d {the event of a Participant's death, the following shall apply: I I Lccount Transfer: The surviving spouse and/or surviving eligible dependents (as defitied in Section ZIII.F.) of the deceased Participant are immediately eligible to maintain the account and utilize it to and eligible medical benefits specified in Section X above. jUpon notification of a Participant's death, the Participant's account balance will be transferred into the i Vantagepoint Money Market Fund*. The account balance may be reallocated by the surviving spouse or 4f dependents. * Please read the current prospectus carefully prior to investing. An investment in this fund is neither insured nor guaranteed and there can be no assurance that the Fund will be able to maintain a stable net asset value of $1.00 per share. Vantagepoint Mutual :i Funds are distributed by ICMA-RC Services, LLC, a controlled affiliate of ICMA Retirement Corporation. Member NASD/SIPC. If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the balance will be available for medical benefits for the designated beneficiary of the last dependent or spouse to die. Assets remaining upon the death of a designated beneficiary shall be available for medical benefits of the beneficiary's designated beneficiary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in Section VIII. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's spouse's or dependent's designated beneficiary(ies). If there are no living spouse or dependents at the time of death of the Participant, the account will be available for medical benefits for the designated beneficiary(ies) of the Participant. Assets remaining upon the death of all designated beneficiaries shall be available for medical benefits of the beneficiary's benefi- ciary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in Section VIII. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's beneficiary(ies) or any beneficiary's beneficiary, XII. Termination Prior to Benefit Eligibility This section replaces the Severance Feature previously included in Section XII. In the case of a Participant's termination of employment in advance of retirement (as defined in Section VILC.) or prior to becoming eligible for medical benefits under the plan (as defined in Section IX.), the 13 Plan Number: 80 Q 9 0 4 vested value of the Participant's account will be available for benefits: ,I Immediately upon termination of employment. As outlined in Section IX. At age XIII.G. Upon termination of employment prior to a Participant becoming eligible for medical benefits from aVantageCare Retirement Health Savings Plan account, Participant accounts that are considered de minimis as specified below will be paid to the Participant. The de minimis account value shall be $5,000 or less. 0 The de minimis account value shall be E (insert dollar amount between $0 and $5,000) or less. 0 The Plan shall not allow de minimis account distributions. EMPLOYER //��r:��•—/�i- Attest- %�� Accepted: Vantagepoint Transfer Agents, LLC Corporate Treasurer 14 ATTACHMENT C DECLARATION OF AMENDMENT TO THE VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN Plan Number: 8Q Q L 7 Name of Employer: ViLLAGE of Elx Ctcooe VW A& State: =LLt The Employer is amending its VantageCare Retirement Health Savings (RHS) Plan to incorporate the provisions selected below. Section numbers refer to the appropriate section of the VantageCare RHS Adoption Agreement. Part I• Addition of New Participation and Contribution Features: Complete Part I if you wish to add the new participation and/or contribution features to your RHS plan. Effective Date: StJUAF_Y (_ 206C (insert effective date of amendment). V. Eligible Groups and Participant Eligibility Requirements Use this section to allow your employees to choose to participate in the RHS program. If you do not select this option, participation will continue to be mandatory for the employee group(s) named in your original RHS Adoption Agreement. If you choose this option, employees that do not opt to participate in RHS will not receive mandatory contributions or be allowed to choose to make elective employee contributions (see SectionVI). Irrevocable Election to Participate If this box is checked, in lieu of mandatory participation, the Employer provides for a one-time irrevocable election by eligible Employees to participate in RHS. Until such time as the election is made, the Employee shall not participate in the Plan or receive contributions pursuant to sectionVI of the RHS Adoption Agreement. Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of initial eligibility during which they may make the election to participate. Participation may -begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to partici- pate may be made in a later year. An annual election window of days (no more than 60 calendar days) shall be provided during which the election may be made.The election win- dow shall run from to (insert your annual time frame for the election win- dow, e.g. October 1 to November 29). Participation may begin no earlier than the calendar year fol- lowing the year of the election. Once made, the election is irrevocable and may not be revoked while the participant is a member of the group covered by the RHS plan. Plan Number: 80 O _l Z Existing RHS participants If you have chosen to allow your employees to elect toparticipate in RHS, you must choose one option below with respect to existing participants. Existing RHS Participants shall be allowed to revoke their participation in the Plan on a one-time irrevocable basis. Participants shall be provided a 60 calendar day window from the effective date of the plan amendment to revoke participation. Revocation shall be made on a form provided by the ICMA Retirement Corporation and returned to the Employer. Once participation is revoked, the Participant may not elect to participate in the Plan at any later time. Account assets of Participants that revoke participation shall remain in the Trust to be distributed under the terms of the Plan as outlined in the Employees VantageCare RHS Adoption Agreement. 0 Existing RHS Participants shall not be allowed to revoke their participation in the Plan. By adopting the elective participation option, the Employer acknowledges that the Internal Revenue Service has not ruled on an irrevocable election to participate in an integral part trust. ICMA-RC has obtained the advice of counsel that such an election is allowable under the conditions outlined in this Adoption Agreement. The Employer should discuss this issue with appropriate counsel. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan, is in whole or part, a non -collectively bargained, self-insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxa- tion on the benefits received by highly compensated Employees if the Plan discriminates in favor of highly compensated Employees in terms of eligibility or benefits. The Employer should discuss these rules with appropriate counsel. VI. Contribution Sources and Amounts Use sections A and/or B to define your contribution formula(s) for your RHS plan. Section C defines your overall plan contribution maximum (if any). Check the boxes that apply, and complete your fund- ing formula(s). A. Mandatory Contributions 0 1. Direct Employer Contributions: The Employer shall contribute on behalf of each Participant of earnings ori for the P1anYear. Definition of earnings: 4MAI&A[. 64S£ SALARY ( Plan Number: 8_00 1 3- 9- 0 2. Mandatory Leave Contributions: The Employer will make mandatory contributions of leave as follows: Accrued Sick Leave* Accrued Vacation* Other (describe)* _ n 171 Yes 171 No 171 No 171 Yes 0 No * Please provide the formula for determining the accrued leave An Employee shall = have the right to discontinue or vary the rate of mandatory leave contribu- tions. C3 3. Mandatory Employee Compensation Contributions: The Employer will make mandatory contributions of Employee compensation as follows: Reduction in Salary - % of earnings (as defined in VI.A.1.) or $ will be contributed for the PlariYear. Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of mandatory contributions of Employee compensation. B. Elective Contributions: If you wish to provide for elective contributions, complete sections 1 and/or 2 as appropriate. 1. The Employer will permit each Employee to make the following elections to make pre-tax contri- butions to the Plan: a. Irrevocable Election for Pre -Tax Contributions from Compensation: A one-time, irrevocable election of the amount of Employer contributions of compensation made on his or her behalf. 0 Plan Number: 80 Q L 7 1 The Employer limits the amount elected to either a fixed percentage or a range of percentages of an Employee's earnings (as shown below): An/e /0O% of N�E'/aoR LONGE'✓�, .23,.ST !1 % of earnings (as defined in VLA.1.) WRiCi/EJE Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window of __J�L_days (no more than 60 calendar days) shall be provided during which the election may be made. The election window shall run from Ald V / to DE'CENBEC /S (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. *Rb. Irrevocable Election for Pre -Tax Contributions of Accrued Leave: A one-time, irrevocable election of the amount of Employer contributions of accrued C3 sick vacation Cl other (describe) leave made on his or her behalf. The Employer limits the amount elgcted as shown below: Newly eligible Employees shall be provided an election window of days (no more than 60 calendar days) from the date of eligibility during which they may make the election to contribute. Contributions may begin no earlier than the calendar month following the end of the election window. If the Employee does not make the election in the year of initial eligibility, the election to con- tribute may be made in a later year. An annual election window of 416 days (no more than 60 calendar days) shall be provided during which the election may be made.The election window shall run from/JJ ✓ / to &CAMMe- 15 (insert your annual time frame for the election window). Contributions may begin no earlier than the calendar year following the year of the election. Once made, the election is irrevocable and may not be revoked. 10 Plan Number: 8 © 0 1 Z Oc. Annual Prospective Election for Pre -Tax Contributions of Leave: An annual, irrevocable elec- tion to have his or her sick vacation X other (describe) leave to be accrued in the next calendar year, contributed to the Plan on its or her behalf. Contributions of future leave accruals will be remitted to the Plan /' Z' 3ox-, y cif FL(J/?T/AJFi �(dOG/O/i�',� 2, ✓'Just' 0.0c AV$-, c��P as earned at the end of the calendar year Ti.NE e44A&6',0 The election to contribute must be made in the calendar year before the year in which contributions are to begin. Once made, the election shall apply to succeeding calendar years unless otherwise revised or revoked by the Employee on an annual basis. An annual election window of '116 days (no more than 60 calendar days) is provided during whitf h eligible Employees may make the election to contribute. The election window shall run fromht I to QEcSAMA /3 of the year prior to the year contributions of leave will begin (insert your annual time frame for the election window). The Employer limits the amount elected as shown below: In adopting section a, b, and/or c, the Employer acknowledges that the Internal Revenue Service has not ruled on irrevocable election contributions in an integral part trust. ICMA-RC has obtained -the advice of counsel that such contributions are allowable under the conditions outlined in this Adoption Agreement. The Employer should discuss this issue with appropriate counsel. C3 2. Voluntary After -Tax Contributions: Each Employee may contribute up to % of earnings (as defined inVI.A.l.) or S for the PlanYear on a voluntary after-tax basis. In no event may aggregate Employee voluntary after-tax contributions exceed 25% of total contri- butions in any P1anYear. An Employee shall have the right to discontinue or vary the rate of voluntary after-tax contributions of Employee earnings. In adopting this section, the Employer acknowledges that the Internal Revenue Service has declined to rule on Employee after-tax contributions in an integral part trust. ICMA-RC has obtained the advice of counsel that such contributions are allowable in an insubstantial amount (i.e. no more than 25% of total contributions in any P1anYear).The Employer should discuss this issue with appropriate counsel. C. Limits on Contributions: Use this section to define your overall maximum contributions for all contribution types you selected. (Limits on individual contribution types are defined within the appropriate sections above.) Plan Number: 8-D G J_ **7 1 The total contribution on behalf of each Participant (including both Mandatory and Elective Contributions) for each Plan Year shall not exceed the following limit(s): 0 % of earnings (as defined in VI,A.1.). 19 There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. Part II: Revision of Existing Distribution Features You must complete Part II to incorporate the HRA -required changes into your existing RHS Plan. These changes udll be effective immediately. Affected provisions include: ✓ Long-term care expenses are no longer a qualifying medical expense (see X.) ✓ Death benefits (see XI. and VIII.) ✓ Severance provision (see XII.) ✓ De minimis provision (see XIII. G.) VIII. Forfeiture Provisions: Complete Section VIII. if 1) you did not select a forfeiture provision for your existing plan (e.g. because vesting does not apply to your plan) or 2) you wish to change your existing forfeiture selection. Upon separation. from the service with the Employer, or upon reversion to the Trust of a Participant's account assets remaining upon the Participant's death (as outlined in Section XI.), a Participant's funds shall: 0 Remain in the Trust to be reallocated among all Plan Participants as Direct Employer Contributions for the next and succeeding contribution cycles(s). Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. C3 Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. CJ Revert to the Employer. in the case of separation from service, the Participant's non -vested funds shall be applied as shown above. In the case of reversion due to the Participant's death, the remaining account assets shall be applied as shown above. X. Permissible Medical Benefit Payments Long Term Care Benefits are not eligible for payment under the Plan. 12 Plan Number: S0 0 1 XI. Death Benefit In the event of a Participant's death, the following shall apply: Account Transfer: The surviving spouse and/or surviving eligible dependents (as defined in Section XIII.F.) of the deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participant's account balance will be transferred into the Vantagepoint Money Market Fund*. The account balance may be reallocated by the surviving spouse or dependents. * Please read the current prospectus carefully prior to investing. An investment in this fund is neither insured nor guaranteed and there can be no assurance that the Fund will be able to maintain a stable net asset value of $1.00 per share. Vantagepoint Mutual Funds are distributed by ICMA-RC Services, LLC, a controlled affiliate of ICMA Retirement Corporation. Member NASD/SIPC. If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the balance will be available for medical benefits for the designated beneficiary of the last dependent or spouse to die. Assets remaining upon the death of a designated beneficiary shall be available for medical benefits of the beneficiary's designated beneficiary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in Section VIII. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's spouse's or dependent's designated beneficiary(ies). If there are no living spouse or dependents at the time of death of the Participant, the account will be available for medical benefits for the designated beneficiary(ies) of the Participant. Assets remaining upon the death of all designated beneficiaries shall be available for medical benefits of the beneficiary's benefi- ciary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified in Section VIII. There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's beneficiary(ies) or any beneficiary's beneficiary. XII. Termination Prior to Benefit Eligibility This section replaces the Severance Feature previously included in Section XII. In the case of a Participant's termination of employment in advance of retirement (as defined in Section VII.C.) or prior to becoming eligible for medical benefits under the plan (as defined in Section IX.), the 13 Plan Number: 8O G 1 ,Z 9 vested value of the Participant's account will be available for benefits: 10 Immediately upon termination of employment. As outlined in Section IX. 0 At age XlH.G. Upon termination of employment prior to a Participant becoming eligible for medical benefits from a VantageCare Retirement Health Savings Plan account, Participant accounts that are considered de minimis as specified below will be paid to the Participant. C3 The de minimis account value shall be $5,000 or less. C] The de minimis account value shall be $ (insert dollar amount between $0 and $5,000) or less. 0 The Plan shall not allow de minimis account distributions. EMPLOYER Attest<::,!� Accepted: Vantagepoint Transfer Agents, LLC Corporate Treasurer 14