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HomeMy WebLinkAboutContract 39073 CITY SECRETARY CONTRACT NO. ADMINISTRATIVE SERVICES AGREEMENT Type: VantageCare RHS Account Number: 803075 rOFFICIAL RECORD �SECRETARY WORTH, TX Plan# 803075 ADMINISTRATIVE SERVICES AGREEMENT This Agreement, made as of the,,*gl 0 day of AwaS-f , 200�(herein referred to as the "Inception Date"),between The International City Management Association Retirement Corporation ("ICMA-RC"), a nonprofit corporation organized and existing under the laws of the State of Delaware;and the City of Fort Worth('Employer")a local governmental instrumentality organized and existing under the laws of the State of Texas with an office at 1000 Throckmorton Street,Fort Worth,Texas 76102. RECITALS Employer acts as a public plan sponsor for a retiree health plan with responsibility to obtain investment alternatives and services for employees participating in that plan; Employer desires to make the VantageCare Retirement Health Savings Plan("RHS Plan"or"Plan") provided by ICMA-RC available to its employees; ICMA-RC makes available the Vantagepoint Funds, a no-load, diversified mutual fund, for investment of public employer plan assets, including RHS Plan assets; ICMA-RC provides a complete offering of services to public employers for the operation of employee retirement and retiree health savings plans including,but not limited to,communications concerning investment alternatives,account maintenance,account record-keeping,investment and tax reporting, form processing,benefit disbursement and asset management. AGREEMENTS 1. Acceptance of RHS Plan Employer agrees to make the RHS Plan provided by ICMA-RC available to its employees. The details of the RHS Plan shall be as mutually agreed between the Employer and ICMA-RC, and in general shall be as set forth in the RHS Plan materials developed by ICMA-RC and provided to Employer. The RHS Plan materials are hereby incorporated by reference and made a part of this Agreement, except that Employer and ICMA-RC may from time to time mutually agree in writing to terms that vary from the RHS Plan materials. RHS plan materials shall include the VantageCare RHS Employer Manual, available electronically through the EZ Link System upon plan adoption. The functions to be performed by ICMA-RC and;its agents include: (a) allocation in accordance with participant direction of individual accounts to investment funds("Funds")made available to Plan participants; (b) maintenance of individual accounts for participants reflecting amounts contributed, OFFICIAL RECORD - 2 - CITY SECRETARY FT.WORTH,TXC Plan# 803075 income, gain, or loss credited, and amounts disbursed as benefits; (c) provision of periodic reports to the Employer and participants of the status of Plan investments and individual accounts; (d) communication to participants of information regarding their rights and elections under the Plan; (e) disbursement of benefits as agent for the Employer in accordance with terms of the Plan;and (f) performance of tax withholding and reporting in conjunction with the Employer for each RHS account. 2. Employerty to Furnish Information Employer agrees to furnish to ICMA-RC on a timely basis such information as is necessary for ICMA-RC to carry out its responsibilities with respect to the Plan,including information needed to allocate individual participant accounts to Funds, and information as to the employment status of participants, and participant ages, addresses, beneficiaries and other identifying information (including tax identification numbers). ICMA-RC shall be entitled to rely upon the accuracy of any information that is furnished to it by a responsible official of the Employer or any information relating to an individual participant,dependent,or beneficiary that is furnished by such participant, dependent, or beneficiary, and ICMA-RC shall not be responsible for any error arising from its reliance on such information. ICMA-RC will provide account information in reports,statements or accountings. 3. Certain Representations and Warranties ICMA-RC represents and warrants to Employer that: (a) ICMA-RC is a non-profit corporation with full power and authority to enter into this Agreement and to perform its obligations under this Agreement. (b) ICMA-RC is an investment adviser registered as such with the Securities and Exchange Commission under the Investment Advisers Act of 1940,as amended.ICMA-RC Services, LLC (a wholly owned subsidiary of ICMA-RC) is registered as a broker-dealer with the Securities and Exchange Commission (SEC) and is a member in good standing of the Financial Industry Regulatory Authority (FINRA). Employer represents and warrants to ICMA-RC that: (c) Employer is organized in the form and manner recited in the opening paragraph of this Agreement with full power and authority to enter into and perform its obligations under this - 3 - Plan# 803075 Agreement and to act for the Plan and participants in the manner contemplated in this Agreement. Execution,delivery,and performance of this Agreement will not conflict with any law,rule,regulation or contract by which the Employer is bound or to which it is a party. (d) Information required to be retained by the Employer shall be set forth in the RHS plan materials developed by ICMA-RC and provided to the Employer. (e) Employer is responsible for determining that there are no state or local laws that would prohibit it from establishing ICMA-RC's VantageCare RHS program. Employer is also responsible for determining that the investments selected for the RHS plan fall within state/local requirements. (f) Employer acknowledges that the RHS plan may be treated as a "health plan" for Health Insurance Portability and Accountability Act ("HIPAA") purposes and therefore may be subject to HIPAA privacy rules.If it is determined that the RHS plan is considered a"health plan", an employer sponsoring RHS would be responsible for complying with the HIPAA privacy and security rules regarding protected health information of RHS plan participants. ICMA-RC has procedures in place to safeguard the protected health information of RHS plan participants. 4. Participation in Certain Proceedings The Employer hereby authorizes ICMA-RC to act as agent,to appear on its behalf, and to join the Employer as a necessary party in all legal proceedings involving the garnishment of benefits or the transfer of benefits pursuant to a medical child support order. Unless Employer notifies ICMA-RC otherwise, Employer authorizes ICMA-RC to determine whether disbursement of benefits to a former spouse, spouse or child pursuant to a medical child support order is appropriate. 5. Compensation and Payment (a) Absent an explicit agreement to the contrary between ICMA-RC and Employer,participant fees and expenses shall be payable from RHS assets,in accordance with the requirements of the RHS Plan as set forth below. (i) Employer with ICMA-RC §401 and §457 retirement plan average participant account balances of$25,000 or more: A $30 annual account fee will be charged to each Accountholder's account upon attainment of Benefit Eligibility by the Accountholder. Benefit Eligibility shall be transmitted electronically to ICMA-RC by Employer through the EZ Link System. Benefit Eligibility shall mean the quarter in which the Accountholder becomes - 4 - Plan# 803075 eligible to use of the account for reimbursement of medical expenses under the terms of the Employer's RHS Plan. The account fee will be charged against the account on a quarterly basis. In addition to the annual account fee, an annual asset fee of 0.30%(30 basis points) will be charged on a quarterly basis,based on the balance in the account on the last day of the previous quarter. (ii) Employer with ICMA-RC §401 and §457 retirement plan average participant account balances of less than$25,000, or Employer who does not currently have a retirement plan with ICMA-RC: A $30 annual account fee will be charged to each Accountholder's account upon attainment of Benefit Eligibility by the Accountholder. Benefit Eligibility shall be transmitted electronically to ICMA-RC by Employer through the EZ Link System. Benefit Eligibility shall mean the quarter in which the Accountholder becomes eligible to use of the account for reimbursement of medical expenses under the terms of the Employer's RHS Plan. The account fee will be charged against the account on a quarterly basis. In addition to the annual account fee,an annual asset fee of 0.40%(40 basis points) will be charged on a quarterly basis,based on the balance in the account on the last day of the previous quarter. When the average participant account balance of the Employer's §401 and §457 retirement plans with ICMA-RC totals$25,000 or more(based on the balances in the Employer's retirement plans on the last day of the previous quarter), the pricing detailed in paragraph 5.a. shall apply beginning in the subsequent quarter. (iii) Account administration fees are subject to change with appropriate prior notification. (b) Compensation for Advisory and other Services to the Vantagepoint Funds. Employer acknowledges that certain wholly-owned subsidiaries of ICMA-RC receive compensation for advisory and other services furnished to the Vantagepoint Funds.The fees referred to in this subsection are disclosed in the Vantagepoint Funds Prospectus. 6. Custody Employer understands that amounts contributed to the RHS plan are to be remitted directly to Vantagepoint Transfer Agents in accordance with instructions provided to Employer in the RHS plan materials and are not to be remitted to the ICMA Retirement Trust or ICMA-RC. In the event that any check or wire transfer is incorrectly labeled or transferred, ICMA-RC will return it to Employer with proper instructions. - 5 - Plan# 803075 7. Responsibility (a) ICMA-RC shall not be responsible for any acts or omissions of any person other than ICMA- RC in connection with the administration or operation of the Plan. (b) The Employer understands that, as a general matter, the Internal Revenue Service("IRS") may decline to rule on certain design features or provisions that the Employer may request to have added to the RHS plan materials. The Employer agrees to hold ICMA-RC harmless in connection with the addition and administration of any RHS plan feature or provision requested by the Employer for which the IRS will not provide express interpretive guidance. 8. Term This Agreement shall be in effect for an initial term beginning on the Inception Date and ending 5 years after the Inception Date. This Agreement will be renewed automatically for each succeeding year unless written notice of termination is provided by either party to the other no less than 60 days before the end of such Agreement year. 9. Amendments and Adjustments (a) This Agreement may not be amended except by written instrument signed by the parties. (b) The parties agree that an adjustment to compensation or administrative and operational services under this Agreement may only be implemented by ICMA-RC through a proposal to the Employer via correspondence or the Employer Bulletin. The Employer will be given at least 60 days to review the proposal before the effective date of the adjustment. Such adjustment shall become effective unless,within the 60 day period before the effective date, the Employer notifies ICMA-RC in writing that it does not accept such adjustment,in which event the parties will negotiate with respect to the adjustment. (c) No failure to exercise and no delay in exercising any right, remedy, power or privilege hereunder shall operate as a waiver of such right, remedy,power or privilege. 10. Notices All notices required to be delivered under Section 9 of this Agreement shall be delivered personally or by registered or certified mail,postage prepaid,return receipt requested,to(i)Legal Department, ICMA Retirement Corporation,777 North Capitol Street,N.E.,Suite 600,Washington,D.C,20002- 4240; (ii) Employer at the office set forth in the first paragraph hereof, or to any other address designated by the party to receive the same by written notice similarly given. 11. Complete Agreement This Agreement shall constitute the sole agreement between ICMA-RC and Employer relating to the - 6 - Plan# 803075 object of this Agreement and correctly sets forth the complete rights,duties and obligations of each party to the other as of its date. Any prior agreements,promises, negotiations or representations, verbal or otherwise, not expressly set forth in this Agreement are of no force and effect. 12. Governing Law This agreement shall be governed by and construed in accordance with the laws of the State of Texas, applicable to contracts made in that jurisdiction without reference to its conflicts of laws provisions. In Witness Whereof,the parties hereto have executed this Agreement as of the Inception Date first above written. CITY OF FORT WORTH APPROVED .TO FOAM AND LEGALITY- ByqJ, �D q Print Name: Karen L . Montgome y Assistant City Attorney Title: Assistant City Manager Attested by INTERNATIONAL CITY/COUNTY LihL�— ' MANAGEMENT ASSOCIATION RETIREMENT CORPORATION Marty HendrixA,ity Secretary FNO M&C rurQ JIRCD BY _ Angela C. Montez Assistant Corporate Secretary i OFFICIAL RECORD _ 7 _ CITY SECRETARY FT. WORTH,TX SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN Plan Number,8 © Z 0-7 J Name of Employer: C I T Y OF 17n yL/ 06K*.: —FX Affirmative Statement of the above-named Employer(the'Employer'). WHEREAS,the Employer has employees rendering valuable services;and WHEREAS,the establishment of a retiree health savings plan 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 the retiree health savings plan(the"Plan")serves the above objectives; NOW THEREFORE,as a duly authorized agent of the Employer,I hereby: ESTABLISH the Employer's Plan in the form of the ICMA Retirement Corporation's VantageCare Retirement Health Savings program;and SPECIFY that the assets of the Plan shall beheld in trust,with the following entity or individual serving as trustee(Select one): Athe Employer ❑ the following position within the Employer: �i,�ttitkderbvld�alaetl,.j..,rr.mel ❑ the following group or committee within the Employer. (imen porp«mmmin,m.oi,Ke tra•tx) ❑ the Mowing third-party trustee: (Lre,c name dthnd-putt nman} for the exclusive benefit of the Plan participants and their survivors,and the assets of the plan shall not be diverted to any other purpose prior to the satisfaction of all liabilities of the Plan.The Employer has executed the Declaration of trust of the Integral Part Trust in the form of:(Select one) XThe model taut made available by the ICMA Retirement Corporation ❑ The trust provided by the Employer(executed copy attached hereto). SPECIFY that the . - PCIN /pl 6219, V shall be the coordinator and contact for the Plan and shall receive necessary reports,notices,etc. DATE: "fl? ���f 'title Designated Agent. Signa EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number:8 03075 Check one: [ New Plan ❑Amendment to Existing Plan Employer Retirement Health Savings Plan Name: I. .Employer Name: City of Fort Worth state: Texas II. The Employer hereby attests that it is a unit of a state or local government or an agency or instrumentality of one or more units of a state or local government. III. Effective Date of the Plan: September 15, 2009 IV.. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s)established by the Employer: V. Eligible Getups,Participation and Participant Eligibility Requirements A. .Eligible Groups The following group or groups of Employees are eligible to participate in the VantageCare Retirement Health Savings Plan(check all applicable boxes): ❑ All Employees ❑ All Full-Time Employees ❑ Non-Union Employees ® Public Safety Employees—Police ❑ Public Safety Employees—Firefighters ❑ General Employees ❑ Collectively-Bargained Employees(Specify unit(s)) ❑ Other(specify group(s)) The Employee group(s)specified must correspond to a group(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 Mandatory Partiripateont Al.l Employees in the coveted group(s)are required to participate in the Plan and shall receive contributions pursuant to Section Vl. ift "'kltlrag tb,V"MieCate Red, � tfi a� '[an is its ar t ai't l re arced s, iu ` n,that etii�i�l sastmt�ittrraa ram ati Merasl drew Vic- (Ili Swaettarrr I� mill .ru nth ''r�.tdaaiana on i be&ts rati+rad 1tuaeopaated icceCivrdit�lai r tl di imiria iri fAim afh40W fir,ntrtd�v ct" t1t+ rulrat wind app+ropciaa�ri�riiel=. C. Participant Eligibility Requirements 1. Minimum service: The minimum period of service required for participation is N/A (write N/A if an Employee is eligible to participate or to elect to participate immediately upon employment). 2. Minimum age:The minimum age required for eligibility to participate is N/A (write NIA if no minimum age is required). VI.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.I.)and Mandatory Employee Compensation Contributions(Section VI.B.2.). Definition of earnings: All W-2 Wages B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ %of Earnings ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year Other(describe): Per attached Meet & Confer Agreement 2. Mandatory Employee Compensation Contributions N/A The Employer will make mandatory contributions of Employee compensation as fellows: ❑ Reduction in Salary- %of Earnings 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. 3. Mandatory Employee Leave Contributions N/A The Employer will make mandatory contributions of accrued leave as follows(provide formula for determining Mandatory Employee Leave contributions): ❑ Accrued Sick Leave ❑ Accrued Vacation Leave ❑ Other(specify type of leave)Accrued Leave An Employee shall shave the right to discontinue or vary the rate of mandatory leave contributions. C. Limits on Total Contributions(check one boa) The total contribution by the Employer on behalf of each Participant(including Direct Employer and Mandatory Employee Contributions) for each Plan Year shall not exceed the following limit(s) below.Limits on individual contribution types are defined within the appropriate section above. ( T}tere is no Plan-defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ %of earnings* *Definition of earnings: ❑ Same as Section VI.A.. ❑ Other ❑ $ for the Plan year. See Section V.B.for a discussion ofnondiscrimination rules that may apply to non-collectively bargained self-insured Plans. VII.Vesting for Direct Employer Contributions A. Vesting Schedule(check one box) ❑ The account is 100%vested at all times. ❑ The following vesting schedule shall apply to Direct Employer Contributions as oudined in Section VI.B.1.: Years of Service Vesting Completed percentage 25 100 % % % B. The account will become 1.00%vested upon the death,disability,retirement*,or attainment of benefit eligibility(as outlined in Section IX) by a Participant. `Definition of retirement(check one box): InRetirement as defined in 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. VII I.Forfeiture.Provisions Upon separation from the service of the Employer prior to attainment of benefit eligibility(as outlined in Section IX),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 non-vested funds shall(check one boa): ®( Remain in the Trust to be reallocared among all remaining Employees participating in the Plan as Direct Employer Contributions for the next and succeeding contribution cycle(s). ❑ Remain in the Trust to be reallocared on.an equal dollar basis among all Plan Participants. ❑ Remain in the Trust ro be reallocated among all Plan Participants based upon Participant account balances. ❑ Revert to the Employer. IX.Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits. �(At retirement only(also complete Section B.) Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑ At separation from service with the following restrictions ❑ No restrictions ❑ Other ❑ At age only ❑ At retirement and age (also complete section B) Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑ At retirement or age Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑ Other,specified as follows(also complete Section B if applicable): B. Termi.nation prior to general benefit eligibility: In the case where the general benefit eligibility as outlined in Section IX.A includes a retirement component,a Participant who separates from the service of the Employer prior to retirement will be eligible to receive benefits: ❑ Immediately upon separation.from service. ❑ At age C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security.Administration X5a as defined by the Employer's primary retirement plan ❑ other will become immediately eligible to receive medical benefit payments from his/her VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant,benefits shall become payable as outlined in.Section.XI. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: All Medical Expenses eligible under IRC Section 213*other than direct long-term care expenses,and including non-prescription medications allowed under IRS guidance. ❑ The following Medical Expenses(select only the expenses you wish to cover under the VantageCare Retirement Health Savings Plan): ❑ Medical Insurance Premiums ❑ Medical Out-of-Pocket Expenses* ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out-of-Pocket Expenses* ❑ Vision Insurance Premiums ❑ Vision Out-of-Pocket Expenm* ❑ Qualified Long-Term Care Insurance Premiums ❑ Non-Prescription medications allowed under IRS guidance* ❑ Other qualifying medical expenses(describe)' *See Section V.A.for a discunion of nondiscriminatiox rules wbich may apply to aon-cogrctA4 bargained,rdJf-inmred Plan. XI.Benefits After the Death of the Participant In the event of a Participant s death,the fallowing shall apply: A. Surviving Spouse and/or Surviving.Dependents The surviving spouse and/or surviving eligible dependents(as defined in Section XII.D.)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 ofa Participant's death,the Participant's account balance will be transferred into the Vantagepoint Money Market Fund`(or another Fund selected by the Employer). The account balance.may be reallocated by the surviving spouse or dependents. *Pleaw read Aw curmat Vantagrpoint Mutual Fundr prvspectw carefully prior to inverting An investment in this fasnd it neither insured nor guaranteed and these can be no auurnnu that the Fund mill be able to maintain is suable net asset udue of$Loo per sham. Vantaggooint Mutaual Fandt are dimibsrted by/CMA-RC Services,LLC a wholly-owned bra c er-dwier of frliate of ICMA Retirement Corporation.MernberAASDI,SIPr I.f 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 account will revert to the Plan to be applied as specified in Section VIII. B. No Surviving Spouse or Surviving Dependents If there arc no living spouse or dependents at the time of death of the Participant,the account will revert to the Plan to be applied as specified in Section VIII. XII.The Plan will operate according to the following provisions A. Employer Responsibilities 1. The Employer will submit all Van.tageCare Retirement Health Savings Plan contribution data via electronic submission. 2. The Employer will submit all VantageCate Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is not limited to termination notification and benefit eligibility notification. 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 an insurance provider(as allowed by the claims administrator). Payments to an third-party payee (e.g.,medical service provider)are not permitted with the exception of reimbursement to the Employer or insurance provider(as allowed by the claims administrator). .D. An eligible dependent is the Participant's lawful spouse and any other individual who is a person described in IRC Section 152(a),as clarified by Internal Revenue Service Notice 2004-79. E. The Employer will be responsible.for withholding,reporting and remitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h),as outlined in the VantageCarc Retirement Health Savings Plan Employer Manual. XHI.Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fi1.1 out this Employer VantageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and/or loss of tax-deferred status for Employer contributions. B. Check this box if you are including supporting documents that include plan provisions. EMPLOYE SIGNATURE By: Date: a O(D' O Title: Assistant City Mana er Attest: Date: Tttie: Accepted:VANTAGEPOI NT TRANSFER AGENTS,LLC APPRO O FORAM AND LEGALITX: C� tiT�CS� Assistant Secretary Assistant City Attorney Vantagetare Retirement Health Savings Plan Implementation Data Form - Page l ICl�ac Instructions to Employer. Provide necessary information to establish your plan properly. e, �c Krs.-wity Please contact your New Business Analyst at 1-800-326-7272,if you have any questions. IO&RC Use Only:Employer# General Information 2. (902) Employer's full Name: C IT V OF TQKr tk)O RT 4 3. eno Strad Address: 100E 14 R Q 0k (_EToN S T R l_ C-T (925) 4. (918) City: OPd zT woi_-7 n4 (919) State:�X (920) lip Codee: o I Oa 5. (633)Primary Contact: T f A Lc. a.o y 6. (634)Primary ContoctTtde: f[S�E m�r— l TS IM A N AC."I F1 7, 1. (631)Primary Contact Telephone#:1 12 8. (632)Fax#:{ 'f a— g g 9. (PT00)E-mail Address: l l it . yi f ' OAT 10. (882)Employer's federal Tax identification Number: 11. #of Employees: 12. #of Employees Etgible for Plan Participation: 13. #of Employees Eligible to Receive Medical Benefits upon plan implementation: Plan Implementation 14. Plan level Quarterly Statements: (Note:"=defoult) Information a. Sort Order: (629) ❑ S=SSN' N=Name b. Output Media: (627) g P=Paper' ❑ M=Microfiche ❑ B=Bound c. Type: (626) ❑ S=Summary' D=Detail 15. (611)Contribution Information:(Note: =defouh) a. Fra* ncy: (check one): ❑ (0)Bi•weekly' ❑ (4)Monthly ❑ (8) Semi-quarterly ❑ (1)Weekly ❑ (5)Sera-Monthy ❑ (9) Bi-oanuallr ❑ (2)Semi-weekly ❑ (6)Bt-quarterly (10)Annually ❑ (3)Bimonthly ❑ (7)Quarterly ❑ (11) Semi-annuolly )C(6h*: TIVAt LP]:171 kf� b. Deposit Medium:(624) Cl (hock' ❑ Wire EF r c. Data Medium: Ellink Required to participate in RNS Plan J. First Contribution Dote Following Impk+mentation: Vantage(are Retirement Health Savings Plan Implementation Data Form - Page 2 IC"RC Phan Contacts g`" R"ti"""°1-C S "'h (Complete item 120. If item#16-19 and 21 are left blank,the Primary Contact in#5 will receive mailings.) Claims Contact 16. Pi01 (orwct$ignalue: x _ Information (2D0) Contact Now: Please indicate (200) Contact Tillie: 3 5 E F 1 T S I'Y1 A lU A alternate addresses in Comments (420) Telephone: (girl)3,7Z 7-7 9 9 Fax: ('Fllh 3q a - n A�f Section 11. PR18 Contact Signature: (200) Contact Now: (2DD) Contact Title: (420) Telephone. ( ) Fax: (_____) 18. PM9 Contact : (200) Contest Now: (200) Contact T#he: (420) Telephone: ( ) Fax: (—) Contribution(00110d 19. PTD2 (200) Contact Hamm: iofarrrofion (2O0) Contact Title: (420) Telephone:( ) - ( ) Trustee Contact 20. Pn0 (2O0) Trustee Name: C 1 T Y OF —VQET WORTH Information '-'R E C-IT V (210) Trustee Title. (310) Trustee Address: _— Ins) street t C)OD —t'ffYZXkN0TeTQN %TEE ET (320) 04�T JA=T� (325)State (330)Zip (420) Telephone:(M) 399 =►-Ig Fax: - TR641 Bing(Fees)Conrad 21. P106 (200) Contact Hama: IM A 1� 1 Pt L rm`-A y Information (200) Contact Tide:'B E KI E F-1 l 5 16A A NA4<E V- (420) Telephone:��) Q oZ-1'7Q 8 Fax: (n )30a" g 8(aa Comments Anoto Addresses far#I6-21) Internal Use Only 641 912 608 1CMA Retirement Corporation* P.O.Box 96220•Washington,DC 20090-6220•Toll Free 1.800 669-7400 ' '°� EZLINK WESS FORM - PAGE 1 OF 2 Plan Name* POL_ PFf 1J?5MEIU F Number' 3d`] Other Plan Numbers) (if Applicable) (*This information must be completedto avoid proycesang dolays.J ^ s� ttII rr 7 Plan Coordinator Name: /11 R R I . la `1 Title:%gJF* 1 �►K Plan Cowdiiiator Phone Number: $`7—312 —-7 71 F Fax:817-3-7.1- Information Email Address:M Af'1,4 G kW Y Q Fo rz )o91 N 6 a V, 0 R tit Mailing Address:\OM J-44`HOC K W1 o�D N 15;7'9!-1 city: 'F 6 ZT WMT H State:-VC Zip: -7& 1 Oa 2 ❑ We hereby adopt Online Withdrawals and authorize icMA-RC to permit disbursements fram participant accounts upon Adoptimt of receipt of termination doin. AddotonaNy,we understand Online W i$rdrovrols are only avo;loble for 401 and 457 plans, Online VYithdrowul termination dates should be submiffad in a Nmely manner,and employer approval is not req►ursd for individual disbursement 4prml 1 requests. (Note:Please conloct an EZUnk SpeckAW at 1-800326.7272,for w6matfon on submitfing termination dates.) 3 Select One: ;`Add New User ID ❑Reassign User ID ❑Update User ID ❑Remove User ID Password Holder Name- WA A R f A \. r rw R�' �� Current User ID: Infamation Tide: C~tF j a P I S- VA A#jf�G?U l Phone#: $L�1=�q`� I Q' Email Address: ) yet(mat Access: proWderbs Inquiry—Balances&Reports ✓Y _N Contributions&Loan Repays t�Y _N ,PossrrmrdHOW Enrollments/Rehires �P _N Participant Data Transfer: 7 Y _N Warn�ausn'to Participant Changes V Y _N establlsb llser ID's (name,address,etc-) for SA&D 1 Select One: ❑Add New User ID ❑Reassign User ID ❑Update User ID ❑Remove User ID imbesof Name: Current User ID: ywrstoff Tide: Phone#: Email Address: Access: Inquiry—Balances&Reports —Y _N Contributions&loan Repays —Y —N Enrollments/Rehires —Y _N Participant Data Transfer: —Y —N Participant Changes _Y _N (name,address,etc.) Select One: ❑Add New User ID ❑Reassign User ID ❑Update User ID ❑Remove User 1D Name: Current User ID: Tide: Phone#: Email Address: Access: Inquiry—Balances&Reports —Y _N Contributions&loan Repays —Y _N Enrollments/Rehires —Y _N Participant Data Transfer: —Y —N Participant Changes _Y _N t f-ram B. address,sir.) (lease fax Yom completed Flunk Access Form to the"EZUnk Administrator"at 1.202-962-4601, HH008-019-2tt5tt IC"R link ,,05 W EZIINK ACCESS FORM - PAGE 2 OF 2 3 Select One: ❑Add New User ID ❑Reassign User ID ❑Update User ID ❑Remove User ID Password Holder Name: Current User ID: Information Title: Phone#: Email Address: (uort6nugdj Access: Inquiry—Bolances&Reports _Y _N Contributions&loon Repays _Y _N Enrollments/Rehires —Y _N Participant Data Transfer: _Y `N Participant Changes _Y _N (name,address, etc.) Select One: Cl Add New User ID ❑Reassign User ID ❑Update User ID ❑Remove User ID Name: Current User ID: Title: Phone#: Email Address: Access: Inquiry—Balances&Reports _Y _N Contributions&Loan Repays _Y _N Enrollments/Rehires _Y _N Participant Data Transfer: _Y _N Participant Changes _Y _N (name, address, eft) 4 ICMA-RC considers participant information to 6e highly confidential,and we go to great lengths to avoid Plan Coordnator (yreaching that confidentiality.For this reason,ICMA-RC cannot 6e responsible for(i)negligent or intentional Approval misuse of the password by the municipality's officers,employees,agents or contractors, (ii)a breach of confidentiality that may occur as a result of such negligent or intentional misuse of the password,or(iii)a An t00400tof 6reach of confidentiality that may occur as a proximate result of the municipality's access to the participant User ID and database.If the municipality uses EZLink online transaction processing, please remem6er to review all PaMW financial information you have entered for your participants,as ICMA-RC is not re3ponsi6le for incorrect data oulemat transmitted 6y the municipality.ICMA-RC recommends that you encourage all participants to review statements ge+te►ated) and confirmations for accuracy. ICMA-RC's Web site is normally availoble 24 hours a day,seven days a week.However,service availability is not guaranteed.Neither ICMA-RC or its affiliates,the Van"Trust Company,nor The Vantagepoint Funds will 6e responsi6le for any loss(or forgone gain)you may incur as a result of service being unavoila6le. Please signify your agreement to these terms 6y signing in the space indicated below.You may fax this signed form to the EZLink Administrator at 1-202-961-4601.We will provide you with User ID(s)and Pos.word(s)to begin using EZLink.Should you have questions regarding EZUnk,please contact an EZUnk Specialist at 1-800-326-7272. Agreed• Date: Plan Coordinator Print Your Name Please fax your completedEZUnk Access Farm to the'EZUnkddministmtoi at1.2029624601. tttrOcO-ott-2ccsoe t „