HomeMy WebLinkAbout11. Approve HRA Plan Document and Third-Party Administrator agreement for Unrepresented and Management Group employees Page 1 of 53
Item 11.
CENTRAL SAN BOARD OF DIRECTORS
POSITION PAPER
MEETING DATE: MAY 5, 2022
SUBJECT: ADOPT NEW PLAN DOCUMENT FOR AN EMPLOYEE-FUNDED HEALTH
REIMBURS EMENTARRANGEMENT (HRA) PLAN AND EXECUTE AN
AGREEMENT WITH A THIRD-PARTYADMINISTRATOR, MISSIONSQUARE
RETIREMENT, TO ADMINISTER THE HRA FOR THE UNREPRESENTED
AND MANAGEMENT GROUP EMPLOYEES; AND AUTHORIZE THE
DISTRICT'S PLAN ADMINISTRATOR TO EXECUTE AND IMPLEMENT THE
REQUIRED PLAN DOCUMENTS
SUBMITTED BY: INITIATING DEPARTMENT:
TEJI O'MALLEY, HUMAN RESOURCES AND OFFICE OF THE GENERAL MANAGER -
ORGANIZATIONAL DEVELOPMENT HUMAN RESOURCES
MANAGER
REVIEWED BY: KEVIN MIZUNO, FINANCE MANAGER
Roger S. Bailey
General Manager
ISSUE
Board approval is required to adopt a plan document for a Health Reimbursement Arrangement (HRA)
and execute an agreement with a Third Party Administrator(TPA)to administer the HRA.
BACKGROUND
In December 2, 2021, the Board adopted a tentative agreement with the Management Group that, in part,
allowed for the represented Managers to participate and contribute employee funds in an HRA, and on
March 24, 2022, the Board adopted a resolution allowing for the same benefit for unrepresented
employees.
An HRA allows eligible employees to, upon termination of employment with the District, obtain
reimbursement of post-employment Health Care Premium expenses from any funds that have been
contributed to the HRA. This benefit has been in place for both MS/CG and Local #1 bargaining units
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since 2019 with the primary difference being that those funds are funded by the District, and this plan will
be funded by employee's own funds hence the adoption of a new plan document (Attachment 1).
Although the Board has already approved the benefit and its implementation via the adoption of the
tentative agreement and the resolution, the Board must now adopt the plan document to ensure Internal
Revenue Code compliance.
Additionally, the Board must approve the execution of an agreement (Attachment 2)with MissionSquare
Retirement to administer the HRA.
ALTERNATIVES/CONSIDERATIONS
As this item has been negotiated with the Management Group and with the unrepresented employees, not
approving this action would be in violation of the tentative agreement and the resolution that approved this
benefit.
FINANCIAL IMPACTS
There are no financial impacts to the District by this action as the HRA will be employee funded.
COMMITTEE RECOMMENDATION
This matter was not reviewed by a Board Committee.
RECOMMENDED BOARD ACTION
Adopt a new plan document for an employee-funded Health Reimbursement Arrangement (HRA) Plan
and execute an agreement with a third-party administrator, MissionSquare Retirement, to administer the
HRA for the Unrepresented and Management Group employees; and authorize the District's Plan
Administrator to execute and implement the required plan documents.
Strategic Plan re-In
GOAL THREE: Fiscal Responsibility
Strategy 2—Ensure integrity and transparency in financial management
GOAL FOUR: Workforce Development
Strategy 2—Foster relationships across all levels of Central San, Strategy 3— Inspire employee engagement
ATTACHMENTS:
1. HRA Plan Document for Management Group and Unrepresented At-Will Employees
2. Administrative Services Agreement with MissionSquare Retirement
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Attachment 1
CENTRAL CONTRA COSTA SANITARY DISTRICT
HEALTH REIMBURSEMENT ARRANGEMENT
FOR TIER III EMPLOYEES REPRESENTED BY
THE MANAGEMENT GROUP
AND UNREPRESENTED AT-WILL EMPLOYEES
Effective April 18, 2022
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TABLE OF CONTENTS
PAGE
ARTICLE I ESTABLISHMENT AND PURPOSE OF THE PLAN ..................................................1
ARTICLE 11 DEFINITIONS............................................................................................................1
ARTICLE III ELIGIBILITY AND PARTICIPATION ........................................................................3
ARTICLE IV CONTRIBUTIONS AND FUNDING..........................................................................4
ARTICLE V VESTING AND BENEFITS .......................................................................................5
ARTICLE VI APPEALS PROCEDURE.........................................................................................7
ARTICLE VII PLAN ADMINISTRATION .......................................................................................8
ARTICLE VIII AMENDMENT AND TERMINATION OF THE PLAN .............................................9
ARTICLE IX GENERAL PROVISIONS.......................................................................................10
APPENDIX A: HIPAA COMPLIANCE......................................................................................A-1
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CENTRAL CONTRA COSTA SANITARY DISTRICT
HEALTH REIMBURSEMENT ARRANGEMENT
FOR TIER III EMPLOYEES REPRESENTED BY
THE MANAGEMENT GROUP
AND UNREPRESENTED AT-WILL EMPLOYEES
Effective April 18, 2022
ARTICLE I
ESTABLISHMENT AND PURPOSE OF THE PLAN
The Central Contra Costa Sanitary District (the Employer) hereby establishes this Central
Contra Costa Sanitary District Health Reimbursement Arrangement for Tier III Employees
Represented by the Management Group and Unrepresented At-Will Employees (the Plan),
effective April 18, 2022 (the Effective Date) to enable Eligible Employees to, upon termination of
employment with the Employer, obtain reimbursement of post-employment Health Care
Premium Expenses.
The Plan is intended to qualify as a health reimbursement arrangement within the meaning of
Internal Revenue Service Notice 2002-45, and it is intended that the benefits under the Plan be
tax-free to the maximum extent permitted under the Internal Revenue Code and the regulations
issued thereunder. The Plan will be administered and interpreted to accomplish that objective.
Capitalized terms used in this Plan that are not otherwise defined have the meanings set forth in
Article ll.
ARTICLE II
DEFINITIONS
2.1 "Board of Directors" means the governing body of the Employer.
2.2 "CCCERA" means the Contra Costa County Employees' Retirement Association in
which the Employer is a participating agency.
2.3 "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended.
2.4 "Code" means the Internal Revenue Code of 1986 and the Treasury Regulations and
guidance issued thereunder, as amended.
2.5 "Dependent" means (a) a dependent as defined in Code Section 152, determined
without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof, and (b) any child (as defined
in Code Section 152(f)) of the Participant who as of the end of the taxable year has not attained
age 27.
2.6 "Effective Date" means April 18, 2022.
2.7 "Eligible Employee" is defined in Section 3.1
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2.8 "Employee" means a person whom the Employer classifies as a common-law
employee and who is on the Employer's W-2 payroll, but does not include the following: (a) any
leased employee (including but not limited to those individuals defined as leased employees in
Code Section 414(n)) or an individual classified by the Employer as a contract worker,
independent contractor, temporary employee, or casual employee for the period during which
such individual is so classified, whether or not any such individual is on the Employer's W-2
payroll or is determined by the IRS or others to be a common-law employee of the Employer;
and (b) any individual who performs services for the Employer but who is paid by a temporary or
other employment or staffing agency for the period during which such individual is paid by such
agency, whether or not such individual is determined by the IRS or others to be a common-law
employee of the Employer.
2.9 "Employer" means the Central Contra Costa Sanitary District.
2.10 "FMLA" means the Family Medical Leave Act of 1993, as amended.
2.11 "Health Care Premium Expenses" are defined in Section 5.5(b).
2.12 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as
amended.
2.13 "HRA Account" means an account described in Section 5.7.
2.14 "Legacy Member" means an Employee who (a) first became a member of CCCERA
before the effective date of PEPRA (January 1, 2013), and who has either remained a CCCERA
member without a break in service of more than six months or returned to work with the same
employer, or (b)was a member of another public retirement system before that date and subject
to reciprocity under CCCERA with that retirement system.
2.15 "Management Group" means the formally recognized exclusive employee
representative for all Management Employees, other than the General Manager, Secretary of
the District, and Unrepresented Employees, of the Employer.
2.16 "Mandatory Employee Contributions" means the amounts the Employee must
contribute to his or her HRA Account in accordance with Section 4.1.
2.17 "Participant" means an Eligible Employee who has satisfied the requirements to
participate in the Plan in Section 3.2 and whose participation in the Plan has not terminated
under Section 3.4.
2.18 "PEPRA" means the California Public Employees' Pension Reform Act of 2013.
2.19 "PEPRA Member" means an Employee who first becomes a member of CCCERA on or
after the effective date of PEPRA (January 1, 2013), or who, after a break in service of more
than six months, returns to work with a different employer, and who either (a) was not a member
of any other public retirement system before that date, or (b)was a member of another public
retirement system before that date, but not subject to reciprocity under CCCERA with that
retirement system.
2.20 "Period of Coverage" is defined in Section 5.3.
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2.21 "Plan" means this Central Contra Costa Sanitary District Health Reimbursement
Arrangement for Tier III Employees Represented by the Management Group and
Unrepresented At-Will Employees, as set forth herein and amended from time to time.
2.22 "Plan Administrator" means the Employer unless the Employer designates another
person or organization to hold the position of Plan Administrator. The Employer may
alternatively designate another person or organization to perform certain duties assigned to the
Plan Administrator under this Plan.
2.23 "Plan Year" means the calendar year (i.e., the 12-month period commencing January 1
and ending on December 31).
2.24 "Trust" means the legal entity that the Employer establishes or adopts to hold any Plan
assets that have been irrevocably set aside to pay benefits under the Plan in accordance with
Section 4.2.
2.25 "Unrepresented Employee" means an Employee in the unrepresented at-will position
of Deputy General Manager, Human Resources Manager, Director of Engineering and
Technical Services, or Director of Finance and Administration.
2.26 "USERRA" means the Uniformed Services Employment and Reemployment Rights Act
of 1994, as amended.
ARTICLE III
ELIGIBILITY AND PARTICIPATION
3.1 Eligible Employee. "Eligible Employee" means each full-time Employee who is:
a) represented by the Management Group or successor association and either:
1) a CCCERA Legacy Member hired by the Employer after June 30, 2009;
or
2) a CCCERA PEPRA Member hired by the Employer after June 30, 2019;
or
b) an Unrepresented Employee hired by the Employer after June 30, 2009.
3.2 Commencement of Participation. Each Eligible Employee on the Effective Date will
participate in the Plan on that date. Each other Employee will become a Participant, eligible to
make Mandatory Employee Contributions to his or her HRA Account under Section 4.1, when
he or she becomes an Eligible Employee.
3.3 No Benefits Unless Eligible. An Employee will not have any interest under the Plan
unless and until he or she satisfies all of the requirements under Section 3.1. Any person who
does not satisfy these requirements will not be entitled to any benefits under the Plan.
3.4 Termination of Participation. A Participant's participation in the Plan terminates upon
the earliest of:
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a) the Participant's ceasing to be an Eligible Employee or exhaustion of his or her
HRA Account, whichever occurs later;
b) the Participant's death without a surviving spouse or Dependent; or
C) the Plan's termination date.
3.5 Reemployment. If the Employer reemploys a Participant, the Participant's coverage
and any reimbursements provided under the Plan to that Participant will cease upon
reemployment. The Participant will not be entitled to coverage or any reimbursements under the
Plan until his or her subsequent termination of employment. If the Participant is reemployed as
an Eligible Employee, he or she will resume participation in the Plan upon reemployment solely
for purposes of eligibility to make Mandatory Employee Contributions to his or her HRA Account
under Section 4.1 until his or her subsequent termination of employment. If a Participant is
reemployed in an ineligible classification (e.g., part-time, temporary, or a classification
represented by a bargaining unit other than the Management Group) he or she will again have
to satisfy the requirements in Section 3.1 before he or she can resume participation in the Plan
for purposes of eligibility to make Mandatory Employee Contributions to his or her HRA Account
under Section 4.1.
ARTICLE IV
CONTRIBUTIONS AND FUNDING
4.1 Mandatory Employee Contributions. Each payroll period, each Participant must
contribute a Mandatory Employee Contribution to his or her HRA account equal to the following
percentage of his or her base salary for the payroll period:
a) Management Group Participants: 1.5% of base salary.
b) Unrepresented Employee Participants: 7% of base salary.
Mandatory Employee Contributions will be deducted on a pretax basis from the Participant's
salary each payroll period, and are intended to be treated as Employer contributions for taxation
purposes under Code.
4.2 Trust. The Employer will establish or adopt a tax-exempt irrevocable Trust to hold Plan
assets. The Trust will specifically provide, among other things, for the investment and
reinvestment of the Trust assets and the income thereof, the management of the Trust assets,
the responsibilities and immunities of the trustee, removal of the trustee and appointment of a
successor, accounting by the trustee and the disbursement of the Trust assets. The trustee will,
in accordance with the terms of the Trust, accept and receive all contributions paid to it by the
Employer, and shall hold, invest, reinvest and manage such moneys and any increment,
increase, earnings and income thereof for the exclusive benefit of Participants and their
spouses and Dependents and for the payment of reasonable expenses of administering the
Plan.
4.3 Participant-Directed Investments. Each Participant may, at the time and manner
prescribed by the Plan Administrator, direct the trustee to invest the Participant's HRA Account
in specific assets, investment funds or other investments permitted under the Trust. If a
Participant fails to designate the permitted assets, investment fund or other investments in
which his or her HRA Account is invested, his or her HRA Account will be invested in the
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investment fund designated by the Plan Administrator. Upon the Participant's death, the
Participant's surviving spouse will have the same right to direct the investment of, and receive
benefits from, the Participant's HRA Account. If the Participant does not have a surviving
spouse or upon the surviving spouse's death, the Participant's Dependents will have the same
right to direct the investment of, and receive benefits from, in shares designated by the
Participant in writing at the time and manner prescribed by the Plan Administrator, of the
Participant's HRA Account. If the Participant properly designates those shares, and the number
of the Participant's Dependents subsequently changes, the Participant must make a new
designation in the same manner. If the Participant fails to properly designate those shares,
either initially or subsequently upon a change in the number of his or her Dependents, the
Participant's Dependents will have the same right to direct the investment of, and receive
benefits from, equal shares of the Participant's HRA Account. To the maximum extent permitted
by law, no Plan fiduciary, including the Employer, the trustee, or the Plan Administrator, will be
liable for any losses which are the direct and necessary result of investment instructions by a
Participant or his or her spouse or Dependents. Any fees or expenses incurred in connection
with a Participant's investment direction and any fees or expenses associated with a particular
investment option, including but not limited to brokerage, investment advisor and management
fees, will be charged to the Participant's HRA Account.
ARTICLE V
VESTING AND BENEFITS
5.1 Vesting. A Participant's HRA Account is immediately 100% non-forfeitable to the extent
of contributions made to such HRA Account.
5.2 Benefit Eligibility. A Participant will not become eligible to receive reimbursements
under the Plan until he or she terminates employment with the Employer. Upon termination of
employment, a Participant will be eligible to receive reimbursements under the Plan during a
Period of Coverage.
5.3 Period of Coverage. Each Participant's Period of Coverage for reimbursements begins
when he or she terminates District employment and ends if and when he or she is reemployed
by the Employer. Therefore, Health Care Premium Expenses incurred by a Participant before
such termination or during any reemployment will not be eligible for reimbursement under the
Plan.
5.4 Benefits. The Plan will reimburse each eligible Participant's Health Care Premium
Expenses up to the unused amount in the Participant's HRA Account as set forth and adjusted
under Section 5.7.
5.5 Health Care Premium Expenses. Under the HRA Account, a Participant may receive
reimbursement for Health Care Premium Expenses incurred during a Period of Coverage.
a) Incurred. A Health Care Premium Expense is incurred at the time the health
insurance coverage or Medicare coverage premium is due and owing. Health
Care Premium Expenses incurred before a Participant first becomes covered by
the Plan are not eligible.
b) Health Care Premium Expenses Generally. "Health Care Premium Expenses"
means expenses incurred by a Participant or his or her spouse or Dependents
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for group or individual health insurance coverage or Medicare Part A and B or
Part C.
C) Cannot Be Reimbursed or Reimbursable From Another Source. Health Care
Premium Expenses may be reimbursed from the Participant's HRA Account only
to the extent that the Participant or other individual incurring the expense is not
reimbursed for the expense (nor is the expense reimbursable) through other
insurance, or any other accident or health plan. If only a portion of a Health Care
Premium Expense has been reimbursed elsewhere, the HRA Account may
reimburse the remaining portion of such expense if it otherwise meets the
requirements of this Article V.
5.6 Maximum Benefits. No reimbursement will be made to the extent that such
reimbursement would exceed the Participant's HRA Account balance.
5.7 Establishment of Account. The Plan Administrator will establish and maintain an HRA
Account for each Participant. The "HRA Account" so established will be a separate
recordkeeping account which will be credited with any Mandatory Employee Contributions and
any attributable investment income and gains, and debited with any allocable expenses,
investment losses and reimbursements.
5.8 Carryover and Forfeitures. If any balance remains in the Participant's HRA Account at
the end of a Plan Year after all reimbursements have been made for the Plan Year, the unused
balance will be carried over to reimburse the Participant for Health Care Premium Expenses
incurred during a subsequent Plan Year. However, any balance that remains in an individual's
HRA Account after he or she has ceased to be a Participant under Section 3.4 (e.g., because
the individual has died without any surviving spouse or Dependents) and after all
reimbursements have been made for any Health Care Premium Expenses incurred before then
will be forfeited. In addition, any benefit payments that are unclaimed (e.g., uncashed benefit
checks) by the close of the Plan Year following the Plan Year in which the Health Care Premium
Expenses were incurred will be forfeited. Forfeitures during a Plan Year will be allocated
immediately following the end of the Plan Year (or Plan termination date, if earlier) per capita
(equal dollar amount) to the HRA accounts of all Participants with a balance at the end of the
Plan Year (or Plan termination date, if earlier).
5.9 Reimbursement Procedure.
a) Timing. Within 30 days after receipt by the Plan Administrator of a
reimbursement claim from a Participant, the Employer will reimburse the
Participant for the Participant's Health Care Premium Expenses (if the Plan
Administrator approves the claim), or the Plan Administrator will notify the
Participant that his or her claim has been denied (see Article VI regarding
procedures for claim denials and appeals procedures). The 30-day time period
may be extended for an additional 15 days for matters beyond the control of the
Plan Administrator, including in cases where a reimbursement claim is
incomplete. The Plan Administrator will provide written notice of any extension,
including the reasons for the extension, and will allow the Participant 45 days in
which to complete an incomplete reimbursement claim.
b) Claims Substantiation. A Participant who seeks benefits may apply for
reimbursement by submitting an application in writing to the Plan Administrator in
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such form as the Plan Administrator may prescribe, within two years of the date
the Health Care Premium Expense was incurred, setting forth:
(i) the individual on whose behalf Health Care Premium Expenses have
been incurred;
(ii) the nature and date of the Health Care Premium Expenses so incurred;
(iii) the amount of the requested reimbursement; and
(iv) a statement that such Health Care Premium Expenses have not
otherwise been reimbursed and are not reimbursable through any other
source.
The application shall be accompanied by bills, invoices, or other statements from
an independent third party (e.g., an insurance carrier) showing that the Health
Care Premium Expenses have been incurred and the amounts of such Health
Care Premium Expenses, together with any additional documentation that the
Plan Administrator may request.
C) Claims Denied. For reimbursement claims that are wholly or partially denied, see
the appeals procedure in Article VI.
5.10 Reimbursements After Termination of Participation. When a Participant ceases to
be a Participant under Section 3.4, the Participant will not be eligible to receive reimbursements
for Health Care Premium Expenses incurred after his or her participation terminates. However,
such Participant (or the Participant's estate) may claim reimbursement for any Health Care
Premium Expenses incurred during the Period of Coverage prior to termination of participation,
provided that the Participant (or the Participant's estate) files a claim within two years of the date
Health Care Premium Expenses were incurred.
ARTICLE VI
APPEALS PROCEDURE
6.1 Notice of Denied Claims. If a claim for reimbursement under this Plan is wholly or
partially denied, the Plan Administrator or its designee will issue a notice of claim denial to the
claimant setting forth:
a) the reason(s) for the denial and the Plan provisions on which the denial is based;
b) a description of any additional information necessary for the claimant to perfect
his or her claim, why the information is necessary, and the time limit for
submitting the information; and
C) a description of the claimant's right to request the documentation relevant to his
or her claim.
6.2 Appeals of Denied Claims. If a claim for benefits is denied under Section 6.1, the
claimant or his or her duly authorized representative may, at the claimant's sole expense,
appeal the denial by submitting written notice of such appeal to the Plan Administrator within
180 days of the receipt of written notice of the denial.
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The Plan Administrator will notify the claimant of the decision on the appeal within 60 days of
receipt of the appeal. The notice of decision on the appeal must be made in writing. If the
decision on the appeal is not furnished within the time specified above, the appeal of the claim
will be deemed denied. If the claimant's appeal is denied (or deemed denied), the Plan
Administrator's decision will be final and binding on all persons.
ARTICLE VII
PLAN ADMINISTRATION
7.1 Plan Administrator. The administration of this Plan will be under the supervision of the
Plan Administrator. It is the principal duty of the Plan Administrator to see that this Plan is
carried out, in accordance with its terms, for the exclusive benefit of persons entitled to
participate in this Plan.
7.2 Powers of the Plan Administrator. The Plan Administrator will have such duties and
powers as it considers necessary or appropriate to discharge its duties. It will have the exclusive
right to interpret the Plan and to decide all matters thereunder, and all determinations of the
Plan Administrator with respect to any matter hereunder will be conclusive and binding on all
persons. Without limiting the generality of the foregoing, the Plan Administrator will have the
following discretionary authority:
a) to construe and interpret the Plan, including all possible ambiguities,
inconsistencies, and omissions in the Plan and related documents, and to decide
all questions of fact, questions relating to eligibility and participation, and
questions of benefits under the Plan;
b) to prescribe procedures to be followed and the forms to be used by Participants
and their spouses and Dependents to claim reimbursements under the Plan;
C) to prepare and distribute information explaining the Plan and the benefits under it
in such manner as the Plan Administrator determines to be appropriate;
d) to request and receive from all Participants and their spouses and Dependents
such information as the Plan Administrator will from time to time determine to be
necessary for the proper administration of the Plan;
e) to furnish each Participant and his or her spouse and Dependents with such
reports with respect to the administration of this Plan as the Plan Administrator
determines to be reasonable and appropriate;
f) to receive, review, and keep on file such reports and information regarding the
benefits covered by the Plan as the Plan Administrator determines from time to
time to be necessary and proper;
g) to appoint and employ such individuals or entities to assist in the administration
of the Plan as it determines to be necessary or advisable, including legal counsel
and benefit consultants;
h) to sign documents for the purposes of administering the Plan, or to designate an
individual or individuals to sign documents for the purposes of administering the
Plan;
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i) to secure or require such evidence as it deems necessary to decide any claim for
benefits under the Plan; and
j) to maintain the books of accounts, records, and other data in the manner
necessary for proper administration of the Plan and to meet any applicable
disclosure and reporting requirements.
7.3 Fiduciary Duties. Each Plan fiduciary shall discharge its duties solely in the interest of
Participants and their spouses and Dependents and for the exclusive purpose of providing
benefits under the Plan, or defraying reasonable expenses of administering the Plan. Each Plan
fiduciary, in carrying out such duties and responsibilities, shall act with the care, skill, prudence
and diligence under the circumstances then prevailing that a prudent person acting in a like
capacity and familiar with such matters would use. A fiduciary may serve in more than one
fiduciary capacity and may employ one or more persons to render advice with regard to its
fiduciary responsibilities. If the fiduciary is serving as such without compensation, all expenses
reasonably incurred by such fiduciary will be paid by the Employer. The Employer may,
however, elect to have those expenses paid from Trust assets.
7.4 Provision for Third-Party Plan Service Providers. The Plan Administrator, subject to
approval of the Employer, may employ the services of such persons as it may deem necessary
or desirable in connection with the operation of the Plan. Unless otherwise provided in the
service agreement, obligations under this Plan shall remain the obligation of the Employer or
Plan Administrator, as applicable.
7.5 Inability to Locate Payee. If the Plan Administrator is unable to make payment to any
person to whom a payment is due under the Plan because it cannot ascertain the identity or
whereabouts of such person after reasonable efforts have been made to identify or locate such
person, then such payment and all subsequent payments otherwise due to such person will be
forfeited by the close of the Plan Year following the Plan Year in which the Health Care
Premium Expense was incurred.
7.6 COBRA and HIPAA Compliance. The Plan will comply with the applicable
requirements of COBRA, and with the applicable requirements of HIPAA in accordance with the
rules set out in Appendix A.
ARTICLE VIII
AMENDMENT AND TERMINATION OF THE PLAN
8.1 Compliance with Labor Laws. All amendments to or any person's benefits under the
Plan or termination of the Plan will conform with any applicable requirements of the Meyers-
Milias-Brown Act, including but not limited to any meet-and-confer requirements.
8.2 No Vested Rights. The Employer may at any time amend or terminate the Plan as
provided in Sections 8.3 and 8.4. Nothing in the Plan is intended to or will be construed to give
any Participant or other person to a vested right to continuance of the Plan or to continue
receiving Employer Contributions.
8.3 Amendment of the Plan. The Employer may amend all or any part of this Plan at any
time for any reason by resolution of the Board of Directors or by any person or persons
authorized by the Board of Directors to take such action. Any such amendment will supersede
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and override any claim to "vested rights" that any person may otherwise have with respect to
benefits under the Plan.
8.4 Termination of the Plan.
a) The Employer has established the Plan with the expectation that it will be
continued, but continuance is not a contractual or other obligation of the
Employer and no employee of the Employer or other person will have any vested
right to continuance of the Plan or to continuance of any Employer contributions
to the Plan. The Employer reserves the right at any time to terminate the Plan
without prejudice and for any reason, and such termination will supersede and
override any claim to "vested rights" that any person may otherwise have with
respect to benefits under the Plan. Such decision to terminate the Plan will be
made in writing and must be approved by the Board of Directors.
b) If the Plan is terminated, the Employer shall direct the trustee to compute the
value of the Plan assets under the Trust as of the date of termination. Those
assets will continue to be held in the Trust, and will be distributed to pay any
remaining benefits owed under the Plan until those benefits are satisfied.
C) The "partial termination" rules of the Code that apply to qualified retirement plans
will not apply under this Plan, and no action will be taken with respect to this Plan
in connection with any event or events that would be a partial termination for a
qualified plan.
8.5 Determination of Effective Date of Amendment or Termination. Any such
amendment, discontinuance or termination will be effective as of the date the Employer
determines.
8.6 Assets After Termination. Any assets remaining in the Trust after all forfeitures have
been allocated and all benefits owed under the Plan and all Plan expenses have been paid will
revert to the Employer unless otherwise determined by the Employer.
8.7 Limitation of Obligations. The Employer must continue to provide reimbursements for
eligible expenses incurred by Participants or their spouses and Dependents under the Plan until
the Participant's account balance has been exhausted, but all contributions to the Plan will
cease upon Plan termination. No Employee will make any additional Mandatory Employee
Contributions under the Plan after its termination.
ARTICLE IX
GENERAL PROVISIONS
9.1 Governing Law. The provisions of the Plan will be construed, administered and
enforced according to applicable federal law and, to the extent not preempted, the laws of the
State of California.
9.2 Requirement for Proper Forms. All communications in connection with the Plan made
by a Participant or his or her spouse or Dependent will become effective only when duly
executed on any forms as may be required and furnished by, and filed with, the Employer or
Plan Administrator, as applicable.
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9.3 No Guarantee of Tax Consequences. This Plan is intended to permit Participants or
their spouses or Dependents to obtain reimbursement benefits under this Plan on a nontaxable
basis, and the Plan will be interpreted and administered consistent with that intent. Neither the
Employer nor any Plan Administrator, however, makes any warranty or other representation as
to whether any benefits under the Plan will be treated as excludable from gross income for
federal, state, or local income tax purposes. If for any reason it is determined that any amount
paid for the benefit of a Participant or his or her spouse or Dependent is includable in gross
income for federal, state or local income tax purposes, then under no circumstances will the
recipient have any recourse against the Employer or Plan Administrator with respect to any
increased taxes or other losses or damages suffered by the recipient as a result thereof. To the
extent required by the Code, the Employer will follow the tax withholding and reporting
requirements applicable to benefits paid under this Plan to or for a non-dependent domestic
partner.
9.4 Compliance With Code and Other Applicable Laws. It is intended that the Plan meet
all applicable requirements of the Code and all regulations and guidance issued thereunder.
The Plan will be construed, operated and administered accordingly, and in the event of any
conflict between any part, clause, or provision of the Plan and the Code, the provisions of the
Code will be deemed controlling, and any conflicting part, clause, or provision of the Plan will be
deemed superseded to the extent of the conflict. In addition, the Plan will comply with the
requirements of all other applicable laws.
9.5 Headings. The headings of the various articles and sections are inserted for
convenience of reference and are not to be regarded as part of the Plan or as indicating or
controlling the meaning or construction of any provision.
9.6 Severability. Should any part of the Plan subsequently be invalidated by a court of
competent jurisdiction, the remainder of the Plan will be given effect to the maximum extent
possible.
9.7 Administration Expenses. The Employer will pay the reasonable expenses of
administering the Plan, including but not limited to the reasonable compensation of any counsel,
accountants, and other agents hired by the Employer, Plan Administrator, or Board of Directors,
as well as any other expenses incurred in administering the Plan. The Employer may, however,
elect to have those expenses paid from Trust assets.
9.8 Effect of Mistake. In the event of a mistake as to the eligibility or participation of an
individual, or the allocations made with respect to any Participant, or the amount of distributions
made or to be made to a Participant or other person, the Employer or Plan Administrator will, to
the extent it deems possible, cause to be allocated or cause to be withheld or accelerated, or
otherwise make adjustment of, such amounts as will in its judgment accord to such Participant
or other person that to which he or she is properly entitled under the Plan.
9.9 No Contract of Employment. The Plan does not provide any person with any right to
be retained in the Employer's employment or service. A Participant's sole rights under the Plan
are limited to those described in this document.
9.10 Plan Provisions Controlling. The Plan encompasses the benefits provided by the
Employer to Participants. In the event that the terms or provisions of any summary or
description of the Plan are interpreted as being in conflict with the provisions of the Plan as set
forth in this document, the provisions of the Plan will be controlling.
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9.11 Non-Assignability of Rights. The right of any Participant or spouse or Dependent to
receive any reimbursement under this Plan will not be alienable by the Participant or spouse or
Dependent by assignment or any other method and will not be subject to claims by his or her
creditors by any process whatsoever. Any attempt to cause such right to be so subjected will not
be recognized, except to the extent required by law.
9.12 Compliance with Other Federal Laws. Notwithstanding any Plan provision to the
contrary, contributions, benefits, and service credit with respect to qualified military service and
FMLA leaves of absence will be provided as required by USERRA or the FMLA, as applicable.
To record the adoption of the Plan, the Employer's authorized representative hereby executes
this document on this day of 2022.
Central Contra Costa Sanitary District
By:
Title:
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APPENDIX A: HIPAA COMPLIANCE
A.1 Provision of Protected Health Information to Employer
Members of the Employer's workforce have access to the individually identifiable health
information of Plan participants for administrative functions of the Plan. When this health
information is provided from the Plan to the Employer, it is Protected Health Information (PHI).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing
regulations restrict the Employer's ability to use and disclose PHI. The following HIPAA
definition of PHI applies for purposes of this Appendix A:
Protected Health Information. Protected health information means information that is created or
received by the Plan and relates to the past, present, or future physical or mental health or
condition of a participant; the provision of health care to a participant; or the past, present, or
future payment for the provision of health care to a participant; and that identifies the participant
or for which there is a reasonable basis to believe the information can be used to identify the
participant. Protected health information includes information of persons living or deceased.
The Employer will have access to PHI from the Plan only as permitted under this Appendix A or
as otherwise required or permitted by HIPAA. HIPAA and its implementing regulations were
modified by the Health Information Technology for Economic and Clinical Health Act (HITECH
Act), the statutory provisions of which are incorporated herein by reference.
A.2 Permitted Disclosure of Enrol lment/Disenrollment Information
The Plan may disclose to the Employer information on whether the individual is participating in
the Plan.
A.3 Permitted Uses and Disclosure of Summary Health Information
The Plan may disclose Summary Health Information to the Employer, provided that the
Employer requests the Summary Health Information for the purpose of modifying, amending, or
terminating the Plan.
"Summary Health Information" means information (a) that summarizes the claims history, claims
expenses, or type of claims experienced by individuals for whom a plan sponsor had provided
health benefits under a health plan; and (b)from which the information described at 42 CFR
Section 164.514(b)(2)(i) has been deleted, except that the geographic information described in
42 CFR Section 164.514(b)(2)(i)(B) need only be aggregated to the level of a five-digit ZIP
code.
A.4 Permitted and Required Uses and Disclosure of PHI for Plan Administration
Purposes
Unless otherwise permitted by law, and subject to the conditions of disclosure described in
Section A.5 and obtaining written certification pursuant to Section A.7, the Plan may disclose
PHI to the Employer, provided that the Employer uses or discloses such PHI only for Plan
administration purposes. "Plan administration purposes" means administration functions
performed by the Employer on behalf of the Plan, such as quality assurance, claims processing,
auditing, and monitoring. Plan administration functions do not include functions performed by
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the Employer in connection with any other benefit or benefit plan of the Employer, and they do
not include any employment-related functions.
Notwithstanding the provisions of this Plan to the contrary, in no event will the Employer be
permitted to use or disclose PHI in a manner that is inconsistent with 45 CFR Section
164.504(f).
A.5 Conditions of Disclosure for Plan Administration Purposes
The Employer agrees that with respect to any PHI (other than enrollment/disenrollment
information and Summary Health Information, which are not subject to these restrictions)
disclosed to it by the Plan, the Employer will:
• not use or further disclose the PHI other than as permitted or required by the
Plan or as required by law;
• ensure that any agent, including a subcontractor, to whom it provides PHI
received from the Plan agrees to the same restrictions and conditions that apply
to the Employer with respect to PHI;
• not use or disclose the PHI for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Employer;
• report to the Plan any use or disclosure of the information that is inconsistent with
the uses or disclosures provided for of which it becomes aware;
• make available PHI to comply with HIPAA's right to access in accordance with 45
CFR Section 164.524;
• make available PHI for amendment and incorporate any amendments to PHI in
accordance with 45 CFR Section 164.526;
• make available the information required to provide an accounting of disclosures
in accordance with 45 CFR Section 164.528;
• make its internal practices, books, and records relating to the use and disclosure
of PHI received from the Plan available to the Secretary of Health and Human
Services for purposes of determining compliance by the Plan with HIPAA's
privacy requirements;
• if feasible, return or destroy all PHI received from the Plan that the Employer still
maintains in any form and retain no copies of such information when no longer
needed for the purpose for which disclosure was made, except that, if such
return or destruction is not feasible, limit further uses and disclosures to those
purposes that make the return or destruction of the information infeasible; and
• ensure that the adequate separation between the Plan and the Employer (i.e.,
the "firewall"), required in 45 CFR Section 504(f)(2)(iii) is satisfied.
The Employer further agrees that if it creates, receives, maintains, or transmits any electronic
PHI (other than enrollment/disenrollment information and Summary Health Information, which
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are not subject to these restrictions) on behalf of the Plan, it will implement administrative,
physical, and technical safeguards that reasonably and appropriately protect the confidentiality,
integrity, and availability of the electronic PHI, and it will ensure that any agents (including
subcontractors) to whom it provides such electronic PHI agree to implement reasonable and
appropriate security measures to protect the information. The Employer will report to the Plan
any security incident of which it becomes aware.
A.6 Adequate Separation Between Plan and Employer
The Employer will allow the following persons access to PHI: the Human Resources Manager,
the Plan Administrator, and any other Employee who needs access to PHI in order to perform
Plan administration functions that the Employer performs for the Plan (such as quality
assurance, claims processing, auditing, and monitoring). No other persons will have access to
PHI. These specified employees (or classes of employees)will only have access to and use
PHI to the extent necessary to perform the plan administration functions that the Employer
performs for the Plan. In the event that any of these specified employees does not comply with
the provisions of this section, that employee will be subject to disciplinary action by the
Employer for non-compliance pursuant to the Employer's employee discipline and termination
procedures.
The Employer will ensure that the provisions of this Section A.6 are supported by reasonable
and appropriate security measures to the extent that the designees have access to electronic
PHI.
A.7 Certification of Plan Sponsor
The Plan will disclose PHI to the Employer only upon the receipt of a certification by the
Employer that the Plan incorporates the provisions of 45 CFR Section 164.504(f)(2)(ii), and that
the Employer agrees to the conditions of disclosure set forth in Section B.S. Execution of the
Plan by the Employer will serve as the required certification.
A.8 Privacy Official
The Employer will designate a Privacy Official, who will be responsible for the Plan's compliance
with HIPAA. The Privacy Official may contract with or otherwise utilize the services of attorneys,
accountants, brokers, consultants, or other third party experts as the Privacy Official deems
necessary or advisable. In addition and notwithstanding any provision of this Plan to the
contrary, the Privacy Official will have the authority to and be responsible for:
• accepting and verifying the accuracy and completeness of any certification
provided by the Employer under this Appendix;
• transmitting the certification to any third parties as may be necessary to permit
them to disclose PHI to the Employer;
• establishing and implementing policies and procedures with respect to PHI that
are designed to ensure compliance by the Plan with the requirements of HIPAA;
• establishing and overseeing proper training of personnel who will have access to
PHI; and
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• any other duty or responsibility that the Privacy Official, in his or her sole
capacity, deems necessary or appropriate to comply with the provisions of
HIPAA and the purposes of this Appendix A.
A.9 Interpretation and Limited Applicability
This Appendix serves the sole purpose of complying with the requirements of HIPAA and will be
interpreted and construed in a manner to effectuate this purpose. Neither this Appendix nor the
duties, powers, responsibilities, and obligations listed herein will be taken into account in
determining the amount or nature of the benefits provided to any person covered under the
Plan, nor will they inure to the benefit of any third parties. To the extent that any of the
provisions of this Appendix A are no longer required by HIPAA or do not apply to the Plan
because the Plan is otherwise excepted from HIPAA, they will be deemed deleted and will have
no force or effect.
A.10 Service Performed for the Employer
Notwithstanding any other provisions of this Plan to the contrary, all services performed by a
business associate for the Plan in accordance with the applicable service agreement will be
deemed to be performed on behalf of the Plan and subject to the administrative simplification
provisions of HIPAA contained in 45 CFR Parts 160 through 164, except services that relate to
eligibility and enrollment in the Plan. If a business associate of the Plan performs any services
that relate to eligibility and enrollment in the Plan, these services will be deemed to be
performed on behalf of the Employer in its capacity as Plan Sponsor and not on behalf of the
Plan.
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ADMINISTRATIVE SERVICES AGREEMENT
for
Central Contra Costa Sanitary District
Type: RHS
Account Number: 800324
MissiO.IfflSquare
RETIREMENT
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ADMINISTRATIVE SERVICES AGREEMENT
This Agreement, made as of this day, (please enter date)
(herein referred to as the "Inception Date"), between The International City
Management Association Retirement Corporation doing business as
MissionSquare Retirement ("MissionSquare"), a nonprofit corporation organized
and existing under the laws of the State of Delaware; and the Central Contra
Costa Sanitary District ("Employer") a local governmental instrumentality
organized and existing under the laws of the State of California with an office at
5019 Imhoff Place, Martinez, California 94553.
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 Retirement Health Savings ("RHS") Program
provided by MissionSquare available to its employees through the Employer's
integral part trust ("Trust") and the Employer's welfare benefits plan ("Plan");
MissionSquare, or its wholly owned subsidiary, acts as investment adviser to
VantageTrust Company, LLC ("VTC"), the Trustee of VantageTrust II Multiple
Collective Investment Funds Trust ("VantageTrust II);
VantageTrust II is a group trust established and maintained in accordance with
New Hampshire Revised Statutes Annotated section 391 :1 and Internal Revenue
Service Revenue Rulings 81-100 and 2011-1, which provides for the collective
investment and reinvestment of assets of certain tax-exempt, governmental
pension and profit sharing plans, and retiree welfare plans, and other eligible
investors;
VTC makes a series of separate funds(the "MSQ Funds Class S") available through
VantageTrust II for the investment of plan assets as referenced in the Declaration
of Trust and Disclosure Memorandum ("Disclosure Materials");
The MSQ Funds Class S are available only through adoption of VantageTrust II;
and
MissionSquare 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, and benefit disbursement.
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Plan # 800324
AGREEMENTS
1 . Acceptance of RHS Program
Employer agrees to make the RHS Program provided by MissionSquare
available to its employees. The details of the RHS Program shall be as mutually
agreed between the Employer and MissionSquare, and in general shall be as set
forth in the RHS Program materials developed by MissionSquare and provided
to Employer. The RHS Program materials are hereby incorporated by reference
and made a part of this Agreement, except that Employer and MissionSquare
may from time to time mutually agree in writing to terms that vary from the RHS
Program materials. RHS Program materials shall include the VantageCare RHS
Employer Manual, available electronically through the plan sponsor website
upon adoption of the RHS Program.
2 Appointment of MissionSquare
Employer hereby appoints MissionSquare as the exclusive Recordkeeper for the
RHS Plan to perform all non-discretionary functions necessary for the
administration of the RHS Plan with respect to assets in the RHS Plan transferred
to its administration.
The functions to be performed by MissionSquare 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, 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.
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Plan # 800324
3. Employer Duty to Furnish Information
Employer agrees to furnish to MissionSquare on a timely basis such information
as is necessary for MissionSquare 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 benefit eligibility and employment status of
participants, and participants' ages, addresses, dependents, spouses and other
identifying information (including tax identification numbers). Employer also
agrees that it will notify MissionSquare in a timely manner regarding changes in
staff as it relates to various roles. This is to be completed through the plan
sponsor website. MissionSquare 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, spouse or dependent that is
furnished by such participant, spouse or dependent, and MissionSquare shall not
be responsible for any error arising from its reliance on such information.
MissionSquare will provide reports, statements and account information to the
Employer through the plan sponsor website.
4. MissionSquare Representations and Warranties
MissionSquare represents and warrants to Employer that:
(a) MissionSquare is a non-profit corporation with full power and authority to
enter into this Agreement and to perform its obligations under this
Agreement.
(b) MissionSquare is an investment adviser registered as such with the
Securities and Exchange Commission under the Investment Advisers Act
of 1940, as amended.
(c) MissionSquare will handle participant information in the manner described
in the Business Associate Agreement to be executed between the Plan and
MissionSquare, a form of which is provided as Exhibit A to this Agreement.
5. Employer Representations and Warranties
Employer represents and warrants to MissionSquare that:
(a) 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 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
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Plan # 800324
or to which it is a party.
(b) Information required to be retained by the Employer shall be set forth in
the RHS Program materials developed by MissionSquare and provided to
the Employer.
(c) Employer is required to send in contributions through the plan sponsor
website, the online plan administration tool provided by MissionSquare.
(d) Employer is responsible for determining that there are no state or local
laws that would prohibit it from establishing the RHS Program. Employer is
also responsible for determining that the investments selected for the Plan
fall within state or local requirements. MissionSquare shall not be
responsible for monitoring state or local law applicable to retirement plans
or for administering the Plan in compliance with local or state requirements
unless Employer notifies MissionSquare of any such local or state
requirements.
(e) Employer acknowledges that the RHS Plan is a "health plan" for Health
Insurance Portability and Accountability Act ("HIPAA") purposes and
therefore is subject to HIPAA privacy rules. Employer also acknowledges
that the RHS Plan is a Health Reimbursement Arrangement, subject to
applicable provisions of the Affordable Care Act ("ACA"). An employer
sponsoring the Plan is responsible for complying with the HIPAA privacy
and security rules with respect to all protected health information created,
maintained, received, or transmitted in relation to the Plan and is
responsible for complying with the ACA.
(f) Employer acknowledges that certain such services to be performed by
MissionSquare under this Agreement may be performed by an affiliate or
agent of MissionSquare pursuant to one or more other contractual
arrangements or relationships, and that MissionSquare reserves the right
to change vendors with which it has contracted to provide services in
connection with this Agreement without prior notice to Employer.
(g) Employer acknowledges and agrees that MissionSquare does not assume
any responsibility with respect to the selection or retention of the Plan's
investment options. Employer shall have exclusive responsibility for the
selection and retention of the Plan's investment options, including the
selection of the applicable mutual fund share class.
(h) Employer confirms that it has executed a Participation Agreement for
VantageTrust II and acknowledges that it has received the Disclosure
Materials.
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Plan # 800324
6. Participation in Certain Proceedings
The Employer hereby authorizes MissionSquare to act as agent, to appear on its
behalf, and to join the Employer as a necessary party in all legal proceedings
regarding the Plan involving the garnishment of benefits or the transfer of
benefits pursuant to a medical child support order. Unless Employer notifies
MissionSquare otherwise, Employer authorizes MissionSquare to determine
whether disbursement of benefits to a spouse or child pursuant to a medical child
support order is appropriate.
7. Compensation and Payment
Absent an explicit agreement to the contrary between MissionSquare and
Employer, participant fees and expenses shall be payable from RHS assets, in
accordance with the requirements of the RHS Program as set forth below.
(a) Asset-based fees will be included in the daily unit value of each MSQ
Fund Class S, and no separate asset-based fees will be assessed.
(b) A $ 25 annual account administration fee will be charged quarterly
to each Accountholder's account.
(c) The account administration fee is subject to change with
appropriate prior notification.
(d) Compensation for Advisory and other Services to
MissionSquare Funds Class M. Employer acknowledges that
MissionSquare, including certain of its wholly owned subsidiaries,
receives compensation for advisory and other services furnished to
the MSQ Funds Class M, which are collective funds serving as the
underlying funds to certain MSQ Funds Class S.
8. Contribution Remittance
Employer understands that amounts contributed to the Plan are to be remitted
directly to Vantagepoint Transfer Agents in accordance with instructions
provided to Employer in the RHS Program materials and are not to be remitted to
MissionSquare. In the event that any check or wire transfer is incorrectly labeled
or transferred, MissionSquare will return it to Employer with proper instructions.
9. Responsibility
(a) MissionSquare shall not be responsible for any acts or omissions of any
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Plan # 800324
person with respect to the Plan, or its related Trust, other than
MissionSquare in connection with the administration or operation of the
Plan or its related Trust.
(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 Program
materials. The Employer agrees to hold MissionSquare harmless in
connection with the addition and administration of any Plan feature or
provision requested by the Employer for which the IRS will not provide
express interpretive guidance.
10. Indemnification
Employer shall indemnify MissionSquare against, and hold MissionSquare
harmless from, any and all loss, damage, penalty, liability, cost, and expense,
including without limitation, reasonable attorney's fees, that may be incurred by,
imposed upon, or asserted against MissionSquare by reason of any claim,
regulatory proceeding, or litigation arising from any act done or omitted to be
done by any individual or person with respect to the Plan or its related Trust,
excepting only any and all loss, damage, penalty, liability, cost or expense
resulting from MissionSquare's negligence, bad faith, or willful misconduct.
11 . Term
This Agreement shall be in effect for an initial term beginning on the Inception
Date. This Agreement This Agreement may be terminated without penalty by
either party on sixty days advance notice in writing to the other. The Employer
understands and acknowledges that, in the event the Employer terminates this
Agreement (or replaces the MissionSquare PLUS Fund of VantageTrust II as an
investment option in its investment line-up), MissionSquare retains full discretion
to release Plan assets invested in the MissionSquare PLUS Fund in an orderly
manner over a period of up to 12 months from the date MissionSquare receives
written notification from the Employer that it has made a final and binding
selection of a replacement for MissionSquare as administrator of the Plan (or a
replacement investment option for the MissionSquare PLUS Fund).
12. Amendments and Adjustments
(a) This Agreement may be amended by written instrument signed by the
parties.
(b) The parties agree that only an adjustment to compensation or
administrative and operational services under this Agreement may be
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Plan # 800324
implemented by MissionSquare 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, the Employer notifies MissionSquare 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.
13. Notices
All notices required to be delivered under this Agreement shall be delivered
electronically, 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.
14. Complete Agreement
This Agreement, with an executed Business Associate Agreement, shall constitute
the sole agreement between MissionSquare and Employer relating to the 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.
15. Governing Law
This agreement shall be governed by and construed in accordance with the laws
of the State of California, applicable to contracts made in that jurisdiction without
reference to its conflicts of laws provisions.
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Plan # 800324
In Witness Whereof, the parties hereto have executed this Agreement as of the
Inception Date first above written.
CENTRAL CONTRA COSTA SANITARY
DISTRICT
By
Signature / Date
By
Name and Title (Please Print)
THE INTERNATIONAL CITY MANAGEMENT
ASSOCIATION RETIREMENT
CORPORATION doing business as
MISSIONSQUARE RETIREMENT
By
Erica McFarquhar
Authorized Representative
Please return an executed copy of the Agreement to a Delivery Address, either:
(a) Via DocuSign
(b) Electronically to ClientContracts_ICMA-RC@missionsq.org
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Plan # 800324
Exhibit A
RHS HIPAA BUSINESS ASSOCIATE AGREEMENT FOR PLAN NUMBER 800324
This Business Associate Agreement("BA Agreement") supplements and is made part of
the Administrative Services Agreement entered into between Central Contra Costa
Sanitary District on behalf of Plan Number 800324 ("Covered Entity" or "Central
Contra Costa Sanitary District RHS") and The International City Management
Association Retirement Corporation doing business as MissionSquare Retirement
("Business Associate") on (please enter date) , and is effective
as of the effective date of the Administrative Services Agreement(the "Effective Date").
RECITALS
Covered Entity is a group health plan that reimburses medical expenses for eligible
participants, their spouses, and their dependents. Under the Health Information
Portability and Accountability Act of 1996 ("HIPAA"), Covered Entity is required to enter
into this BA Agreement to obtain satisfactory assurances that Business Associate will
appropriately safeguard all Protected Health Information ("PHI"), as defined herein, that
is created, maintained, received, or transmitted by Business Associate on behalf of
Covered Entity.
Business Associate is a record keeper providing administrative services to Covered
Entity. In general, Business Associate will not have access to information that would
traditionally be considered PHI because participant medical information used to
substantiate reimbursements is sent directly to and reviewed by a third-party claims
processor. The third-party claims processor has agreed to protect PHI that it creates,
maintains, receives, or transmits in a manner that is consistent with and as stringent as
the terms agreed to by Business Associate under this BA Agreement with respect to
information that could be considered PHI. Business Associate has access to information
that might be interpreted as PHI, including an individual's participation in the plan,
reimbursement amounts, and the timing of reimbursements.
In consideration of the mutual promises below and the exchange of information pursuant
to this BA Agreement and in order to comply with all legal requirements for the
protection of this information, Covered Entity and Business Associate agree as follows:
1. DEFINITIONS
a. The following terms used in this BA Agreement shall have the same meaning
as those terms are defined in the HIPAA Rules: Breach, Data Aggregations,
Designated Record Set, Disclosure, Health Care Operations, Minimum
Necessary, Notice of Privacy Practices, Secretary, Security Incident,
Subcontractor, Unsecured Protected Health Information, and Use.
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Plan # 800324
b. "Administrative Services Agreement" refers to a separate agreement
outlining the services MissionSquare will provide to Covered Entity and the
terms and conditions governing the provision of such services. The
Administrative Services Agreement is made between MissionSquare and
Central Contra Costa Sanitary District RHS or its sponsor, acting on behalf
of Central Contra Costa Sanitary District RHS.
c. "Business Associate" shall have the same meaning as the term "business
associate" at 45 CFR 160.103, and in reference to this BA Agreement shall
mean MissionSquare.
d. "Covered Entity" shall have the same meaning as the term "covered entity" at
45 CFR 160.103, and in reference this BA Agreement, shall mean Central
Contra Costa Sanitary District RHS.
e. "HIPAA Rules" shall mean the Privacy, Security, Breach Notification, and
Enforcement Rules at 45 CFR Part 160 and Part 164.
f. "Privacy Rule" shall mean the Privacy Standards and Implementation
Specifications at 45 CFR 170 and 164, Subparts A and E.
g. "Protected Health Information" ("PHI") shall have the same meaning as the
term "protected health information" in 45 CFR § 160.103, limited to the
information created, received, maintained, or transmitted by Business
Associate from or on behalf of Covered Entity pursuant to this Agreement.
h. "Security Rule" shall mean the Security Standards and Implementation
Specifications at 45 CFR Parts 160 and 164, Subparts A and C.
2. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
Business Associate agrees to:
a. Not Use or Disclose PHI other than as permitted or required by this BA
Agreement or as required by law.
b. Use appropriate safeguards to prevent Use or Disclosure of PHI other than as
provided for by this BA Agreement, and comply with subpart C of 45 CFR Part
164 with respect to electronic PHI in Business Associate's custody or control,
to prevent Use or Disclosure of PHI other than as provided for by this BA
Agreement.
c. Report to Covered Entity any Use or Disclosure of PHI not provided for by the
BA Agreement of which it becomes aware not more than 60 calendar days
after Business Associate discovers such non-permitted Use or Disclosure,
including Breaches of Unsecured PHI as required at 45 CFR 164.410, and any
Security Incident for which it becomes aware.
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Plan # 800324
d. In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable,
ensure that any Subcontractors that create, receive, maintain, or transmit PHI
on behalf of the Business Associate agree to the same restrictions, conditions,
and requirements that apply to the Business Associate with respect to such
information.
e. Make available, within 30 calendar days of the request of Covered Entity, PHI
in a Designated Record Set in Business Associate's custody or control, to
Covered Entity, or as Directed by Covered Entity, to an individual, so that
Covered Entity may meet its access obligations under 45 CFR § 164.524.
f. Make any amendment(s) to PHI in a Designated Record Set in Business
Associate's custody or control as directed in writing by the Covered Entity
pursuantto 45 CFR 164.526 no laterthan 60 days after receipt of such request,
so that Covered Entity may meet its amendment obligations under 45 CFR
164.526.
g. Maintain and make available the information required to provide an
accounting of Disclosures to the Covered Entity as requested by Covered
Entity in writing and as necessary to satisfy the Covered Entity's obligations
under 45 CFR 164.528.
h. Make its internal practices, books, and records, available to the Secretary for
purposes of determining compliance with the HIPAA Rules.
i. Not directly or indirectly receive remuneration in exchange of PHI.
J. Comply with the administrative simplification rules applicable to standard
transactions, if Business Associate conducts such transactions under the
electronic data interchange rules on behalf of Covered Entity.
k. To the extent the parties agree that Business Associate will carry out directly
one or more of Covered Entity's obligations under the Privacy Rule, the
Business Associate will comply with the requirements of the Privacy Rule that
apply to the Covered Entity in the performance of such obligations.
3. PERMITTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE
a. Business Associate may only Use or Disclose PHI as necessary to perform the
services set forth in the Administrative Services Agreement and as permitted
by this BA Agreement.
b. Business Associate may Use or Disclose PHI as required by law or to report
violations of law to appropriate Federal and State authorities, consistent with
45 CFR 164.502(j)(i).
c. Except as otherwise limited by this BA Agreement, Business Associate agrees
to make Uses and Disclosures and requests for PHI consistent with the
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Plan # 800324
Covered Entity's Minimum Necessary policies and procedures when such are
provided by the Covered Entity to Business Associate.
d. Business Associate is authorized to de-identify information in accordance with
45 CFR 164.514(a)-(c).
e. Business Associate may not Use or Disclose PHI in a mannerthat would violate
Subpart E of 45 CFR Part 164 if done by Covered Entity, except forthe specific
Uses and Disclosures set forth below.
f. Business Associate may Use PHI for the proper management and
administration of the Business Associate or to carry out the legal
responsibilities of the Business Associate.
g. Business Associate may provide Data Aggregation services relating to the
Health Care Operations of the Covered Entity.
4. OBLIGATIONS AND ACTIVITIES OF COVERED ENTITY
a. Covered Entity shall notify Business Associate of any limitations in the Notice
of Privacy Practices that Covered Entity provides to individuals pursuant to 45
CFR 164.520, to the extent that such limitation may affect Business
Associate's Use or Disclosure of PHI.
b. Covered Entity shall notify Business Associate of any changes in, or revocation
of, the permission by an individual to Use or Disclose his or her PHI, to the
extent that such changes may affect Business Associate's Use or Disclosure of
PHI.
c. Covered Entity shall notify Business Associate of any restrictions on the Use or
Disclosure of PHI that Covered Entity has agreed to or is required to abide by
under 45 CFR 164.522, to the extent that such restriction may affect Business
Associate's Use or Disclosure of PHI.
d. Covered Entity shall not request Business Associate to Use or Disclose PHI in
any mannerthat would not be permissible under Subpart E of 45 CFR Part 164
if done by Covered Entity, exceptto the extentthat Business Associate will Use
or Disclose PHI for Data Aggregation or management and administration and
legal responsibilities of the Business Associate.
e. Covered Entity shall notify Business Associate of any confidential
communication requests with which the Covered Entity has agreed to in
accordance with 45 CFR 164.522, to the extent such requests would affect
Business Associate's Use or Disclosure of PHI.
S. TERM AND TERMINATION
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a. This BA Agreement shall be effective as of the Effective Date, and shall
terminate upon the termination of the Administrative Services Agreement,
subject to the provisions below regarding the return or destruction of PHI.
b. Business Associate authorizes termination of this BA Agreement by Covered
Entity, if Covered Entity determines Business Associate has violated a material
term of the BA Agreement, and Business Associate has not cured the Breach
or ended the violation, following written notice to the Business Associate,
within a reasonable period of time not to exceed any reasonable cure period
defined in the Administrative Services Agreement.
c. Upon termination of this BA Agreement for any reason, Business Associate,
with respect to PHI Received from Covered Entity, or created, maintained, or
received from Business Associate on behalf of Covered Entity, shall:
i. Retain only that PHI which is necessary for Business Associate to
continue its proper management and administration or to carry out its
legal responsibilities;
iii. Return to Covered Entity or, if agreed to by Covered Entity, destroy the
remaining PHI that the Business Associate still maintains in any form;
iii. Continue to use appropriate safeguards and comply with Subpart C of
45 CFR Part 164 with respect to electronic PHI to prevent Use or
Disclosure of the PHI, other than as provided for in this Section, for as
long as Business Associate retains PHI;
iv. Not Use or Disclose the PHI retained by Business Associate other than
for the purposes for which such PHI was retained and subject to the
same conditions set out at Paragraph 3(f);
v. Return to Covered Entity or, if agreed to Covered Entity, destroy the
PHI retained by Business Associate when it is no longer needed by
Business Associate for its proper management and administration or
to carry out its legal responsibilities;
vi. Notwithstanding any other provision of this BA Agreement, upon
termination, Business Associate may also transmit PHI to another
Business Associate of the Covered Entity upon the written request of
the Covered Entity.
d. The obligations of Business Associate under Section 5,Term and Termination,
shall survive the termination of this BA Agreement.
6. GENERAL PROVISIONS
a. A reference in this BA Agreement to a section in the HIPAA Rules means the
section as in effect or amended.
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b. The parties agree to take such action as is necessary to amend this BA
Agreement from time to time as is necessary for compliance with the
requirements of the HIPAA Rules and any other applicable laws.
c. Any ambiguity in this BA Agreement shall be interpreted to permit
compliance with the HIPAA rules.
d. Nothing in this BA Agreement shall be construed as creating any rights or
benefits to any third parties.
e. The invalidity and unenforceability of any provision of this BA Agreement shall
not affectthe enforceability of any other provision of this BA Agreement orthe
Administrative Services Agreement, which shall remain in full force and effect.
f. All notices and communications required by this BA Agreement shall be in
writing. Such notices and communications shall be given in one of the
following forms: (i) by delivery in person, (ii) by a nationally recognized, next-
day courier service, (iii) by first-class, registered or certified mail, postage
prepaid, or (iv) by electronic mail to the address that each party specifies in
writing.
g. This BA Agreement and the Administrative Services Agreement constitute the
entire agreement between the parties with respect to its subject matter and
constitute and supersede all prior agreements, representations, and
understandings of the parties, written or oral, with regard to the same subject
matter.
CENTRAL CONTRA COSTA SANITARY DISTRICT RHS
By
Signature / Date
Name and Title (Please Print)
THE INTERNATIONAL CITY MANAGEMENT ASSOCIATION
RETIREMENT CORPORATION doing business as MISSIONSQUARE RETIREMENT
By
Erica McFarquhar
Authorized Representative
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11:4 MissionSquare Retirement Health Savings Program Adoption Book
Suggested Affirmative Statement for Adoption of the MissionSquare Retirement Health Savings
(RHS)Program
Plan Number: 800324
Name of Employer: Central Contra Costa Sanitary District State: California
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 program 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 program
(the "Program")serves the above objectives;
NOW THEREFORE, as a duly authorized agent of the Employer, I hereby:
ESTABLISH the Employer's MissionSquare Retirement Health Savings Program through the Employer's
integral part trust("Trust") and the Employer's welfare benefits plan ("Plan"); and
SPECIFY that the assets of the Plan shall be held in trust, with the following entity or individual serving
as trustee(Select one):
❑the Employer
14 the following position within the Employer: Finance Manager
(insert title of individual acting as trustee)
❑the following group or committee within the Employer:
(insert group or committee acting as trustee)
❑the following third-party trustee:
(insert name of third-party trustee)
for the exclusive benefit of 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 Central Contra Costa Sanitary District
Integral Part Trust in the form of: (Select one)
0 The sample trust made available by MissionSquare Retirement
❑The trust provided by the Employer(executed copy attached hereto)
SPECIFY that the Finance Manager shall be the
coordinator and contact for the Plan and shall receive necessary reports, notices, etc.
Date:
Finance Manager
Title of Designated Agent
Signature
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11:14 MissionSquare Retirement Health Savings Program Adoption Book
Missk1-".-,EnSquare
RETIREMENT
MissionSquare RHS Adoption
Agreement
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11:15 MissionSquare Retirement Health Savings Program Adoption Book
MissionSquare Retirement Health Savings(RHS)Adoption Agreement
Plan Number: 800324
Select as applicable:
❑Standalone RHS ❑Integrated RHS ❑Amendment to Existing Plan ❑✓ New Plan
I. Employer Name: Central Contra Costa Sanitary District State: California
11. 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. Plan Dates:
A. Plan Effective Date April 18,2022
B. Plan Year: Enter the annual accounting period for the RHS program. Calendar Year
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: Central Contra Costa Sanitary District Health
Reimbursement Arrangement for Tier III Employees Re resented b the Management Group and Unrepresented At-Will Employees*
V. Eligible Groups, Participation and Participantigi i i equwremen s
A. Eligible Groups
The following group or groups of Employees are eligible to participate in the Employer's
welfare benefits plan identified in Section IV. (check all applicable boxes):
[]All Employees
❑All Full-Time Employees
❑ Non-Union Employees
❑ Public Safety Employees- Police
❑ Public Safety Employees- Firefighters
❑General Employees
❑l Collectively-Bargained Employees(Specify unit(s)) Management Group CCCERA Legacy Members
hired after June 30,2009 and CCCERA PEPRA Members hired after June 30,2019er
Q ter s p eciy groups nre resente m o ees ire the m o er lune 30 2009
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 Participation:All Employees in the covered group(s)are required to participate in
the Plan and shall receive contributions pursuant to Section VI.
If the Employer's underlying welfare benefit plan is in whole or part a non-collectively
bargained plan that allows reimbursement for medical expenses other than insurance
premiums, the nondiscrimination requirements of Internal Revenue Code(IRC) Section
105(h)will apply. These rules may impose taxation on the benefits received by highly
compensated individuals if the Plan discriminates in favor of highly compensated
individuals in terms of eligibility or benefits.The Employer should discuss these rules with
appropriate counsel.
*The"Plan."To the extent of any conflict between this Adoption Agreement and the Plan,the Plan will control.
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11:16 MissionSquare Retirement Health Savings Program Adoption Book
C. Participant Eligibility Requirements
1. Minimum service: The minimum period of service required for participation is N/A
(write N/A if no minimum service is required).
2. Minimum age: The minimum age required for eligibility to participate is N/A
(write N/A 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.1.)and Mandatory Employee
Compensation Contributions(Section VI.13.2.).
Definition of earnings: Base Salary
B. Direct Employer Contributions and Mandatory Contributions
Contributions for participants include:
1. Direct Employer Contributions
The Employer shall contribute on behalf of each Participant
E1_%of Earnings*
❑$ each Plan Year
❑A discretionary amount to be determined each Plan Year
❑Other(describe):
2. Mandatory Employee Compensation Contributions
The Employer will make mandatory contributions of Employee compensation as follows:
❑A Reduction in Salary—1.5 % of Earnings for Management Group Participants and 7% of Earnings
for Unrepresented Participants will be contributed each payroll period.
❑ 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
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 not have the right to discontinue or vary the rate of mandatory leave
contributions.
* Non-collectively bargained plans that reimburse medical expenses other than insurance premiums should consulttheir
benefits counsel regarding welfare plan nondiscrimination rules if the employer elects to make contributions based on a
percentage of earnings.
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11:17 MissionSquare Retirement Health Savings Program Adoption Book
C. Limits on Total Contributions(check one box)
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.
❑� There 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.
VII.Vesting for Direct Employer Contributions
A. Vesting Schedule(check one box)
❑l The account is 100%vested at all times.
❑ The vesting schedule below shall apply to direct employer contributions as outlined in
Section VI.13.1.
Vesting schedules beyond 10 years are not supported. For vesting schedules that are not
supported, it is the employer's responsibility to maintain and provide the vested
percentage of eligible employees upon benefit eligibility.
Years of Service Vesting
Completed Percentage
B. The account will become 100%vested upon the death,disability,retirement*,or
attainment of benefit eligibility(as outlined in Section IX)by a Participant.
* Definition of retirement includes a separation from service component and is further defined
by(check one):
[]The primary retirement plan of the Employer
✓❑Separation from service
❑Other
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11:18 MissionSquare Retirement Health Savings Program Adoption Book
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.
VIII. Forfeiture Provisions
If a Participant separates from service prior to full vesting, non-vested funds in the Participant's
account shall be forfeited in accordance with the box checked under this section.
Upon the death of a Participant, surviving spouse, and all surviving eligible dependents(as
outlined in Section XI),funds remaining in the Participant's account shall revert to the Trust in
accordance with the box checked under this section.
If a Participant permanently opts out and waives future reimbursements, as allowed under IRS
Notice 2013-54, all funds in the Participant's account at the time of waiver shall be forfeited in
accordance with the box checked under this section.*
❑ Remain in the Trust to be reallocated among all Plan Participants with a balance as Direct
Employer Contributions for the next and succeeding contribution cycle(s).**
Z Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants
with a balance.**
❑ Remain in the Trust to be reallocated among all Plan Participants based upon Participant
account balances.**
IX. Eligibility Requirements to Receive Medical Benefit Payments from the MissionSquare
Retirement Health Savings Program
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
❑l No restrictions
❑Other
B. Termination prior to general benefit eligibility: Ina case where the general benefit
eligibility as outlined in Section IX.A includes a retirement component, a Participant who
separates from service of the Employer prior to retirement will be eligible to receive benefits:
Z Immediately upon separation from service
❑Other
* If the Employer's RHS Program does not limit eligibility to Participants who have separated from service,the Employer will be
required to provide further direction to MissionSquare regarding the treatment of possible contributions that are required to
be made following the Participant's waiver.
** If the forfeited balance is small whereby the reallocation amount to each Plan Participant with a balance is minimal,the assets
will revert to Employer's forfeiture account for further direction from the Employer.If there are Participants without a balance
who should receive forfeiture assets,please provide alternative instructions to MissionSquare on the forfeiture reallocation
notice.
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11:19 MissionSquare Retirement Health Savings Program Adoption Book
C. A Participant who becomes totally and permanently disabled
❑As defined by the Social Security Administration
[:]As defined by the Employer's primary retirement plan
❑Other
will become immediately eligible to receive medical benefit payments from his/her
account under the Employer's welfare benefits plan.
D. Upon the death of the Participant,benefits shall become payable as outlined in
Section XI.
X. Permissible Medical Benefit Payments
Select one option.
Benefits eligible for reimbursement under the plan are as allowed under IRC Section 213 other
than (i)direct long-term care expenses, and (ii)expenses for medicines or drugs which are not
prescribed drugs(other than insulin).
❑ Option 1:All Medical Benefits*
❑1 Option 2: Insurance Premiums Only
❑ Option 3: Select Expenses*you wish to cover under the Employer's welfare benefits plan:
❑Medical Insurance Premiums
❑Medical Out-of-Pocket Expenses
❑Medicare Part B Insurance Premiums
❑Medicare Part D Insurance Premiums
El 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 Expenses
❑Qualified Long-Term Care Insurance Premiums
❑Non-Prescription medications allowed under IRS guidance
❑Other qualifying medical expenses(describe)
* Non-collectively bargained plans that reimburse medical expenses other than insurance premiums should consult their
benefits counsel regarding welfare plan nondiscrimination rules if the employer elects to make contributions based on a
percentage of earnings.
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XI. Benefits After the Death of the Participant
In the event of a Participant's death,the following shall apply:
A. Surviving Spouse and/or Surviving Dependents
Upon the death of a Participant,the deceased Participant's surviving spouse is immediately eligible to
maintain the Participant's account and utilize the remaining balance to fund the benefits specified in
Section X above.After the death of the surviving spouse or if there is no surviving spouse,the surviving
eligible Dependents(as defined in Section XII.D.)of the deceased Participant are immediately eligible to
maintain the Participant's account and utilize the remaining balance to fund the benefits specified in
Section X above as described in Section 4.3 of the Plan.
*Before investing,please read the applicable fund disclosure materials carefully for a complete summary of all fees,
expenses,investment objectives and strategies,and risks. This information is available when you log in at
www.icmarc.org/login,or upon request by calling(800)326-7272.
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 account will revert in accordance
with the Employer's election under Section VIII of the MissionSquare RHSAdoption Agreement.
B. No Surviving Spouse or Surviving Dependents
If there are no living spouse or Dependents at the time of death of the Participant,the
account will revert in accordance with the Employer's election under Section VIII of the
MissionSquare RHS Adoption Agreement.
XII. The Plan Will Operate According to the Following Provisions:
A. Employer Responsibilities
1. The Employer will submit all MissionSquare Retirement Health Savings Plan enrollment
and contribution data via electronic submission.
2. The Employer will submit all MissionSquare Retirement Health Savings Plan Participant
status updates or personal information updates via electronic submission. This includes
but is not limited to termination notification, benefit eligibility, and vesting 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, except to the extent required by law. Otherwise, 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 a 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 (a) a dependent of the Participant as defined in IRC Section 152,
determined without regard to subsections(b)(1), (b)(2), and (d)(1)(B)thereof, and (b) any child (as
defined in IRC Section 152(f)) of the Participant who as of the end of the taxable year has not
attained age 27.
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 MissionSquare Retirement Health Savings Employer Manual.
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11:21 MissionSquare Retirement Health Savings Program Adoption Book
XIII. Employer Acknowledgements
A. The Employer hereby acknowledges it understands that failure to properly fill out this
MissionSquare Retirement Health Savings Adoption Agreement may result in the loss of tax
exemption of the Trust and/or loss of tax-deferred status for Employer contributions.
B. W Check this box if you are including supporting documents that include plan provisions.
Employer Signature
By: Date:
Title:Finance Manager
Attest: Date:
Title:
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11:32 MissionSquare Retirement Health Savings Program Adoption Book
Declaration of Trust of the
Central Contra Costa Sanitary District
Name of Employer
Integral Part Trust
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11:33 MissionSquare Retirement Health Savings Program Adoption Book
Declaration of Trust of the
Central Contra Costa Sanitary District
(Name of Employer)
Integral Part Trust
Declaration of Trust made as of the day of , 20 22 by and between
the(Name of Employer)Central Contra Costa Sanitary District (State)California
a(Type of Entity)local government agency
(hereinafter referred to as the"Employer")and (Name or Title of Trustee) Finance Manager
or its designee(hereinafter referred to as the"Trustee").
Recitals
WHEREAS,the Employer is a political subdivision of the State of(state)California 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 and Dependents 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 and Dependents 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 sample 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 and Dependents;
NOW,THEREFORE,the parties hereto do hereby establish this trust, by executing the sample
Declaration Of Trust Of the(Name of Employer)Central Contra Costa Sanitary District
Integral Part Trust(hereinafter referred to as the"Trust"), and agree that the following constitute the
sample Declaration of Trust(hereinafter referred to as the "Declaration"):
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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) "Administrator" means the Employer or the entity designated by the Employer to carry out
administrative services as are necessary to implement the Plan.
(c) 'Beneficiary" means the Spouse and Dependents, who will receive any benefits payable
hereunder in the event of the Participant's death. In the case where there is no Spouse or
Dependents, any amount of contributions, plus accrued earnings thereon, remaining in the
Account must revert in accordance with the Employer's election under Section VIII of the
MissionSquare RHS Adoption Agreement.
(d) "Code" means the Internal Revenue Code of 1986, as amended from time to time.
(e) "Dependent" means(a)the Participant's lawful spouse, (b)the Participant's child under the
age of 27, as defined by IRC Section 152(f)(1)and Internal Revenue Service Notice 2010-38, or
(c)any other individual who is a person described in IRC Section 152(a), as clarified by Internal
Revenue Service Notice 2004-79.
M "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.
(g) "NonforFeitable Interest" means the interest of the Participant or the Participant's Spouse and
Dependent(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.A
Participant shall, at all times, have a one hundred percent(100%) Nonforfeitable Interest in the
Participant's own contributions.
(h) "Spouse" means the Participant's lawful spouse as determined under the laws of the
jurisdiction in which the Participant was married.
() "Trust" means the trust established by this Declaration.
(j) "Trustee" means the Employer or 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 and Dependents.
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Article III
Construction
3.1 This Trust and its validity, construction and effect shall be governed by the laws of the State of
California
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 pursuant to the terms of the Plan.
4.2 Form of Benefits.This Trust may reimburse the Participant, his Spouse and 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 and Participants'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 or their Spouses and Dependents 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:
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(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, 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.
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
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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 Leave. Contributions up to an amount equal to the value of accrued sick leave,vacation
leave, or other type of accrued leave, as permitted under the Plan.The Employer's Plan must
provide a formula for determining the value of the Participant's contribution of accrued leave.The
Employer's Plan must contain a forfeiture provision that will prevent Participants from receiving the
accrued leave in cash in lieu of a contribution to the Trust.
7.3 Accounts. Employer contributions, including mandatory Participant contributions, and
contributions of accrued leave, 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 and Dependents.The assets in
each Participant's Account may be invested in Investment Funds as directed by the Participant(or,
after the Participant's death, by the Spouse or Dependents)or the Employer, as required under the
Plan,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 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, or Dependent.
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.
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Article VIII
Other Plans
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,their
Spouses and Dependents 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 or Dependents 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.
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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 termination 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.
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Article XIV
Limited Effect of Plan and Trust
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.
Article XV
Protective Clause
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: Title: Finance Manager
TRUSTEE(S):
By: Title: Finance Manager
By: Title:
By: Title:
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