HomeMy WebLinkAboutRESOLUTION - 22-02 - 5/14/2002 - VANTAGE RETIREMENT HEALTH SAVINGS PLANRESOLUTION NO. 22-02
A RESOLUTION AUTHORIZING THE VILLAGE OF ELK GROVE VILLAGE TO
PARTICIPATE IN THE VANTAGE RETIREMENT HEALTH SAVINGS PLAN (ICMA)
WHEREAS, the Employer has employees rendering valuable services; and
WHEREAS, the establishment of a retirement health savings plan for such
employees serves the interests 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 has determined that the establishment of a retiree health
savings plan to be administered by the ICMA Retirement Corporation and/or its affiliates
serves the above objectives; and
WHEREAS, the Employer desires that its retiree health savings plan (the "Plan") be
administered by the ICMA Retirement Corporation and/or its affiliates:
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 as follows:
SECTION 1. That the Employer hereby adopts the Plan in the form of the ICMA
Retirement Corporation's VantageCare Retirement Health Savings Plan.
SECTION 2. That the assets of the Plan shall be held in trust, with the Employer
serving as trustee, for the exclusive benefit of Plan participants and their beneficiaries, and
the assets of the Plan shall not be diverted to any other purpose.
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SECTION 3. That the Human Resources Officer shall be the coordinator and
contact for the Plan and shall receive necessary reports and notices.
SECTION 4. This Resolution shall be in full force and effective immediately from
and after its passage and approval according to law.
VOTE: AYES: 6 NAYS: 0 ABSENT: 0
PASSED this 10 day of May, 2002.
APPROVED this 14' day of May, 2002.
ATTEST:
Ann I. Walsh, Village Clerk
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APPROVED:
Craig B. Johnson, Mayor
RES Reti rementHealth 1.doc
DECLARATION OF TRUST OF THE
INTEGRAL PART TRUST
Declaration of Trust made as of the 14 day of MaY _, 2002 _ byy
and between the Village of Elk Grove VillagQ Illinois
iTif oVEmployer State
a Village (hereinafter referred to as the "Employer") and
Type Oftimity
Village of Elk Grove Village _or its designee (hereinafter referred to as the "Trustee").
Fame..if : mstee
RECITALS:
WHEREAS, the Employer is a political subdivision of the State of
Illinois exempt from federal income tax under the Internal Revenue Code of
1986; and
WHEREAS, the Employer provides for the security and welfare of its eligible
employees (hereinafter referred to as "Participants"), their Spouses, Dependents and
Beneficiaries by the maintenance of one or more post-retirement welfare benefit plans,
programs or arrangements which provide for life, sickness, medical, disability, severance and
other similar benefits through insurance and self-funded reimbursement plans (collectively
the "Plan"); and
WHEREAS, it is an essential function and integral part of the exempt
activities of the Employer to assist Participants, their Spouses, Dependents and Beneficiaries
by making contributions to and accumulating assets in the trust, a segregated fund, for post-
retirement welfare benefits under the Plan; and
WHEREAS, the authority to conduct the general operation and administration
of the Plan is vested in the Employer or its designee, who has the authority and shall be
subject to the duties with respect to the trust specified in this Declaration of Trust; and
WHEREAS, the Employer wishes to establish this trust to hold assets and
income of the Plan for the exclusive benefit of Plan Participants,_ their Spouses, Dependents
and Beneficiaries; and
NOW, THEREFORE, the parties hereto do hereby establish this trust, to be
known as the Declaration of Trust of the _Village of Elk Grove Village Integral Part
Trust (hereinafter referred to as the "Trust'), aro Foree that the following constitute the
Declaration of Trust (hereinafter referred to as the "Declaration"):
ARTICLE I
DEFINITIONS
1.1 Definitions. For the purposes of this Declaration, the following terms
shall have the respective meanings set forth below unless otherwise expressly provided.
(a) "Account" means the individual recordkeeping account maintained
under the Plan to record the interest of a Participant in the Plan in accordance with Section
7.3.
(b) "Account Transfer" means a transfer of the Participant's Account
upon his or her death to be used for the payment of benefits for the Participant's Spouse and
Dependents.
(c) "Administrator" means the Employer. The Employer may contract
for such administrative services as are necessary to implement the Plan.
(d) "Beneficiary" means the person or persons designated by the
Participant pursuant to the terms of the Plan, or, if the Plan provides otherwise, the Spouse
and Dependents, who will receive any benefits payable hereunder in the event of the
Participant's death.
(e) "Code" means the Internal Revenue Code of 1986, as amended from
time to time.
(f) "Covered Employment Classification" means the group or groups of
Participants eligible to have contributions to this Plan made on their behalf, as specified by
the Employer.
(g) "Dependent" means an individual who is a person described in Code
Section 152(a).
(h) "Investment Fund" means any separate investment option or vehicle
selected by the Employer in which all or a portion of the Trust assets may be separately
invested as herein provided. The Trustee shall not be required to select any Investment Fund.
(i) "Non forfeitable Interest" means the interest of the Participant or the
Participant's Spouse, Dependent or Beneficiary (whichever is applicable) in the percentage
of Participant's Employer's contribution which has vested pursuant to the vesting schedule
specified in the Employer's Plan.
0) "Spouse" means the Participant's lawful spouse as determined under
the laws of the state in which the Participant has his primary place of residence.
(k) "Trust" means the trust established by this Declaration.
(1) "Trustee" means the person or persons appointed by the Employer to
serve in that capacity.
ARTICLE II
ESTABLISHMENT OF TRUST
2.1 The Trust is hereby established as of the date set forth above for the
exclusive benefit of Participants, their Spouses, Dependents and Beneficiaries.
ARTICLE III
CONSTRUCTION
3.1 This Trust and its validity, construction and effect shall be governed
by the laws of the State of Illinois
3.2 Pronouns and other similar words used herein in the masculine gender
shall be read as the feminine gender where appropriate, and the singular form of words shall
be read as the plural where appropriate.
3.3 If any provision of this Trust shall be held illegal or invalid for any
reason, such determination shall not affect the remaining provisions, and such provisions
shall be construed to effectuate the purpose of this Trust.
ARTICLE IV
BENEFITS
4.1 Benefits. This Trust may provide benefits to the Participant, the
Participant's Spouse and Dependents. Death benefits may be provided to a Beneficiary
pursuant to the terms of the Plan.
4.2 Form of Benefits. This Trust may provide benefits by cash payment.
This Trust may reimburse the Participant, his Spouse or Dependents for insurance premiums
or other payments expended for permissible benefits described under the Plan. This trust
may reimburse the Employer, or the Administrator for insurance premiums.
ARTICLE V
GENERAL DUTIES
5.1 It shall be the duty of the Trustee to hold title to assets held in respect
of the Plan in the Trustee's name as directed by the Employer or its designees in writing.
The Trustee shall not be under any duty to compute the amount of contributions to be paid by
the Employer or to take any steps to collect such amounts as may be due to be held in trust
under the Plan. The Trustee shall not be responsible for the custody, investment, safekeeping
or disposition of any assets comprising the Trust, to the extent such functions are performed
by the Employer or the Administrator, or both.
5.2 It shall be the duty of the Employer, subject to the provisions of the
Plan, to pay over to the Administrator or other person designated hereunder from time to time
the Employer's contributions under the Plan and to inform the Trustee in writing as to the
identity and value of the assets titled in the Trustee's name hereunder and to keep accurate
books and records with respect to the Participants of the Plan.
ARTICLE VI
INVESTMENTS
6.1 The Employer may appoint one or more investment managers to
manage and control all or part of the assets of the Trust and the Employer shall notify the
Trustee in writing of any such appointment.
6.2 The Trustee shall not have any discretion or authority with regard to
the investment of the Trust and shall act solely as a directed Trustee of the assets of which it
holds title. To the extent directed by the Employer (or Participants, their Spouses and
Dependents, or Beneficiaries to the extent provided herein) the Trustee is authorized and
empowered with the following powers, rights and duties, each of which the Trustee shall
exercise in a nondiscretionary manner:
(a) To cause stocks, bonds, securities, or other investments to be
registered in its name as Trustee or in the name of a nominee, or to take and keep the same
unregistered;
(b) To employ such agents and legal counsel as it deems advisable or
proper in connection with its duties and to pay such agents and legal counsel a reasonable
fee. The Trustee shall not be liable for the acts of such agents and counsel or for the acts
done in good faith and in reliance upon the advice of such agents and legal counsel, provided
it has used reasonable care in selecting such agents and legal counsel;
(c) To exercise where applicable and appropriate any rights of ownership
in any contracts of insurance in which any part of the Trust may be invested and to pay the
premiums thereon; and
(d) At the direction of the Employer (or Participants, their Spouses, their
Dependents, their Beneficiaries, or the investment manager, as the case may be) to sell, write
options on, convey or transfer, invest and reinvest any part thereof in each and every kind of
property, whether real, personal or mixed, tangible or intangible, whether income or non-
income producing and wherever situated, including but not limited to, time deposits
(including time deposits in the Trustee or its affiliates, or any successor thereto, if the
deposits bear a reasonable rate of interest), shares of common and preferred stock,
mortgages, bonds, leases, notes, debentures, equipment or collateral trust certificates, rights,
warrants, convertible or exchangeable securities and other corporate, individual or
government securities or obligations, annuity, retirement or other insurance contracts, mutual
funds (including funds for which the Trustee or its affiliates serve as investment advisor,
custodian or in a similar or related capacity), or in units of any other common, collective or
commingled trust fund.
6.3 Notwithstanding anything to the contrary herein, the assets of the Plan
shall be held by the Trustee as title holder only. Persons holding custody or possession of
assets titled to the Trust shall include the Employer, the Administrator, the investment
manager, and any agents and subagents, but not the Trustee. The Trustee shall not be
responsible or liable for any loss or expense which may arise from or result from compliance
with any direction from the Employer, the Administrator, the investment manager, or such
agents to take title to any assets nor shall the Trustee be responsible or liable for any loss or
expense which may result from the Trustee's refusal or failure to comply with any direction
to hold title, except if the same shall involve or result from the Trustee's negligence or
intentional misconduct. The Trustee may refuse to comply with any direction from the
Employer, the Administrator, the investment manager, or such agents in the event that the
Trustee, in its sole and absolute discretion, deems such direction illegal.
6.4 The Employer hereby indemnifies and holds the Trustee harmless
from any and all actions, claims, demands, liabilities, losses, damages or reasonable expenses
of whatsoever kind and nature in connection with or arising out of (i) any action taken or
omitted in good faith by the Trustee in accordance with the directions of the Employer or its
agents and subagents hereunder, or (ii) any disbursements of any part of the Trust made by
the Trustee in accordance with the directions of the Employer, or (iii) any action taken by or
omitted in good faith by the Trustee with respect to an investment managed by an investment
manager in accordance with any direction of the investment manager or any inaction with
respect to any such investment in the absence of directions from the investment manager.
Notwithstanding anything to the contrary herein, the Employer shall have no responsibility to
the Trustee under the foregoing indemnification if the Trustee fails negligently, intentionally
or recklessly to perform any of the duties undertaken by it under the provisions of this Trust.
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6.5 Notwithstanding anything to the contrary herein, the Employer or, if so
designated by the Employer, the Administrator and the investment manager or another agent
of the Employer, will be responsible for valuing all assets so acquired for all purposes of the
Trust and of holding, investing, trading and disposing of the same. The Employer will
indemnify and hold the Trustee harmless against any and all claims, actions, demands,
liabilities, losses, damages, or expenses of whatsoever kind and nature, which arise from or
are related to any use of such valuation by the Trustee or holding, trading, or disposition of
such assets.
6.6 The Trustee shall and hereby does indemnify and hold harmless the
Employer from any and all actions, claims, demands, liabilities, losses, damages and
reasonable expenses of whatsoever kind and nature in connection with or arising out of (a)
the Trustee's failure to follow the directions of the Employer, the Administrator, the
investment manager, or agents thereof, except as permitted by the last sentence of Section 6.3
above; (b) any disbursements made without the direction of the Employer, the Administrator,
the investment manager or agents thereof, and (c) the Trustee's negligence, willful
misconduct, or recklessness with respect to the Trustee's duties under this Declaration.
ARTICLE VII
CONTRIBUTIONS
7.1 Employer Contributions. The Employer shall contribute to the Trust
such amounts as specified in the Plan or by resolution.
7.2 Accrued Sick Leave and/or Accrued Vacation Leave. Contributions up
to an amount equal to the value of accrued sick leave or vacation leave, or both, are permitted
under the Plan. The Employer's Plan must provide a formula for determining the value of
the Participant's contribution of accrued sick leave or vacation leave, or both. The
Employer's Plan must contain a forfeiture provision that will prevent Participants from
receiving the accrued sick leave or vacation leave, or both, in cash in lieu of a contribution to
the Trust.
7.3 Accounts. Employer contributions and contributions of accrued sick
leave or vacation leave, or both, all investment income and realized and unrealized gains and
losses, and forfeitures allocable thereto will be deposited into an Account in the name of the
Participant for the exclusive benefit of the Participant, his Spouse, Dependents and
Beneficiaries. The assets in each Participant's Account may be invested in Investment Funds
as directed by the Participant from among the Investment Funds selected by the Employer.
7.4 Receipt of Contributions. The Employer or, if so designated by the
Employer, the Administrator or investment manager or another agent of the Employer, shall
receive all contributions paid or delivered to it hereunder and shall hold, invest, reinvest and
administer such contributions pursuant to this Declaration, without distinction between
principal and income. The Trustee shall not be responsible for the calculation or collection
7
of any contribution under the Plan, but shall hold title to property received in respect of the
Plan in the Trustee's name as directed by the Employer or its designee pursuant to this
Declaration.
7.5 No amount in any Account maintained under this Trust shall be
subject to transfer, assignment, or alienation, whether voluntary or involuntary, in favor of
any creditor, transferee, or assignee of the Employer, the Trustee, any Participant, his
Spouse, Dependent, or Beneficiaries.
7.6 Upon the satisfaction of all liabilities under the Plan to provide such
benefits, any amount of Employer contributions, plus accrued earnings thereon, remaining in
such separate Accounts must, under the terms of the Plan, be returned to the Employer.
ARTICLE VIII
OTHER PLANS
8.1 If the Employer hereafter adopts one or more other plans providing
life, sickness, accident, medical, disability, severance, or other benefits and designates the
Trust hereby created as part of such other plan, the Employer or, if so designated by the
Employer, the Administrator or an investment manager or another agent of the Employer
shall, subject to the terms of this Declaration, accept and hold hereunder contributions to
such other plans. In that event (a) the Employer or, if so designated by the Employer, the
Administrator or an investment manager or another agent of the Employer, may commingle
for investment purposes the contributions received under such other plan or plans with the
contributions previously received by the Trust, but the books and records of the Employer or,
if so designated by the Employer, the Administrator or an investment manager or another
agent of the Employer, shall at all times show the portion of the Trust Fund allocable to each
plan; (b) the term "Plan" as used herein shall be deemed to refer separately to each other
plan; and (c) the term "Employer" as used herein shall be deemed to refer to the person or
group of persons which have been designated by the terms of such other plans as having the
authority to control and manage the operation and administration of such other plan.
ARTICLE IX
DISBURSEMENTS AND EXPENSES
9.1 The Employer or its designee shall make such payments from the
Trust at such time to such persons and in such amounts as shall be authorized by the
provisions of the Plan provided, however, that no payment shall be made, either during the
existence of or upon the discontinuance of the Plan (subject to Section 7.6), which would
cause any part of the Trust to be used for or diverted to purposes other than the exclusive
benefit of the Participants and their Beneficiaries pursuant to the provisions of the Plan.
9.2 All payments of benefits under the Plan shall be made exclusively
from the assets of the Accounts of the Participants to whom or to whose Spouse, Dependents,
or Beneficiaries such payments are to be made, and no person shall be entitled to look to any
other source for such payments.
9.3 The Employer, Trustee and Administrator may be reimbursed for
expenses reasonably incurred by them in the administration of the Trust. All such expenses,
including, without limitation, reasonable fees of accountants and legal counsel to the extent
not otherwise reimbursed, shall constitute a charge against and shall be paid from the Trust
upon the direction of the Employer.
ARTICLE X
ACCOUNTING
10.1 The Trustee shall not be required to keep accounts of the investments,
receipts, disbursements, and other transactions of the Trust, except as necessary to perform
its title -holding function hereunder. All accounts, books, and records relating thereto shall be
maintained by the Employer or its designee.
10.2 As promptly as possible following the close of each year, the Trustee
shall file with the Employer a written account setting forth assets titled to the Trust as
reported to the Trustee by the Employer or its designee.
ARTICLE XI
MISCELLANEOUS PROVISIONS
11.1 Neither the Trustee nor any affiliate thereof shall be required to give
any bond or to qualify before, be appointed by, or account to any court of law in the exercise
of its powers hereunder.
11.2 No person transferring title or receiving a transfer of title from the
Trustee shall be obligated to look to the propriety of the acts of the Trustee in connection
therewith.
11.3 The Employer may engage the Trustee as its agent in the performance
of any duties required of the Employer under the Plan, but such agency shall not be deemed
to increase the responsibility or liability of the Trustee under this Declaration.
11.4 The Employer shall have the right at all reasonable times during the
term of this Declaration and for three (3) years after the tennination of this Declaration to
examine, audit, inspect, review, extract information from, and copy all books, records,
accounts, and other documents of the Trustee relating to this Declaration and the Trustees'
performance hereunder.
ARTICLE XII
AMENDMENT AND TERMINATION
12.1 The Employer reserves the right to alter, amend, or (subject to Section
9.1) terminate this Declaration at any time for any reason without the consent of the Trustee
or any other person, provided that no amendment affecting the rights, duties, or
responsibilities of the Trustee shall be adopted without the execution of the Trustee to the
amendment. Any such amendment shall become effective as of the date provided in the
amendment, if requiring the Trustee's execution, or on delivery of the amendment to the
Trustee, if the Trustee's execution is not required.
12.2 Upon termination of this Declaration and upon the satisfaction of all
liabilities under the Plan to provide such benefits, any amount of Employer contributions,
plus accrued earnings thereon, remaining in such separate Accounts must, under the terms of
the Plan, be returned to the Employer.
ARTICLE XIII
SUCCESSOR TRUSTEES
13.1 The Employer reserves the right to discharge the Trustee for any or no
reason, at any time by giving ninety (90) days' advance written notice.
13.2 The Trustee reserves the right to resign at any time by giving ninety
(90) days' advance written notice to the Employer.
13.3 In the event of discharge or resignation of the Trustee, the Employer
may appoint a successor Trustee who shall succeed to all rights, duties, and responsibilities
of the former Trustee under this Declaration, and the terminated Trustee shall be deemed
discharged of all duties under this Declaration and responsibilities for the Trust.
ARTICLE XIV
LIMITED EFFECT OF PLAN AND TRUST
14.1 Neither the establishment of the Plan and the Trust or any modification
thereof, the creation of any fund or account, nor the payment of any benefits, shall be
construed as giving to any person covered under the Plan or other person any legal or
equitable right against the Trustee, the Administrator, the Employer or any officer or
employee thereof, except as may otherwise be expressly provided in the Plan or in this
Declaration.
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ARTICLE XV
PROTECTIVE CLAUSE
15.1 Neither the Administrator, the Employer, nor the Trustee shall be
responsible for the validity of any contract of insurance or other arrangement maintained in
connection with the Plan, or for the failure on the part of the insurer or provider to make
payments provided by such contract, or for the action of any person which may delay
payment or render a contract void or unenforceable in whole or in part.
IN WITNESS WHEREOF, the Employer and the Trustee have executed this
Declaration by their respective duly authorized officers, as of the date first hereinabove
mentioned.
EMPLOYER:
By: . w
Title./11,V46 /lf/h✓XGr•�
Title:
A-
TRUSTEES:
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ATTACHMENT C
DECLARATION OF AMENDMENT TO THE VANTAGECARE RETIREMENT
HEALTH SAVINGS PLAN
Plan Number: 80 0 1 7 8
Name of Employer: Village of Elk Grove Village State: Illinois
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: January 1, 2003 (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 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.
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Plan Number: 8
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.
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
71 1. Direct Employer Contributions: The Employer shall contribute on behalf of each Participant
% of earnings or $ for the P1anYear.
Definition of earnings:
Plan Number: 8_ _ _ _
0 2. Mandatory Leave Contributions: The Employer will make mandatory contributions of leave
as follows:
Accrued Sick Leave*
Yes
0
No
Accrued Vacation*
Yes
17
No
Other (describe)* 71 Yes 0 No
* Please provide the formula for determining the accrued leave contribution:
An Employee shall not have the right to discontinue or vary the rate of mandatory leave contribu-
tions.
[713. 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 P1anYear.
Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or
I 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.
A
Plan Number: 8
The Employer limits the amount elected to either a fixed percentage or a range of percentages of
an Employee's earnings (as shown below):
00 of earnings (as defined in VI.A.1.) or up to % of earnings (as
defined inVI.A.1.) for the Plan Year.
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 (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.
Clb. Irrevocable Election for Pre -Tax Contributions of Accrued Leave:A one-time, irrevocable
election of the amount of Employer contributions of accrued
0 sick 0 vacation 0 other
her behalf.
The Employer limits the amount elected as shown below:
(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 made. The election
window shall run from to (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_
O c. Annual Prospective Election for Pre -Tax Contributions of Leave: An annual, irrevocable elec-
tion to have his or her 0 sick [71 vacation 0 other
(describe)
leave to be accrued in the next calendar year, contributed to the Plan on his or her behalf.
Contributions of future leave accruals will be remitted to the Plan
0 as earned 0 at the end of the calendar year
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 days (no more than 60 calendar days) is provided
during which eligible Employees may make the election to contribute. The election window shall
run from to 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.1.) or $ for the Plan Year 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 Employees all 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
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.1.).
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
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 XIL)
✓ 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:
171 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 0 0 1 7 8
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: 8 0 0 1 7 8
vested value of the Participant's account will be available for benefits:
Immediately upon termination of employment.
As outlined in Section IX.
CI 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.
1401
91 The de minimis account value shall be $5,000 or less.
0 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.
Accepted: Vantagepoint Transfer Agents, LLC
Corporate Treasurer
14