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( <br /> - B. No SurvFlag Spome ar Surdving Dependmq . ' <br /> If [here are no living apouse or dependenra u[he time of de¢th of t6e Participant, the nccount will revert m r6e Plan w <br /> be applied a apedfied in Sec[ion VIII. <br /> RII. The Plan wlll operare aaording m the following ptovisiooe� <br /> A. Employer Bespo°dbilldss <br /> 1. The Empbya will su6anit aR VanssgeCa�e Retuweot Halth Savings Phn contnbution data via dxtronic s�bmiamon. <br /> 2. 'ILe Employa will submic ell VanrageCare R»�+-T•-c Halth Savinga Plan Participan� antua updaua or pasonal <br /> information updaaa via el�ctronic submiuion. This includu bu[ u noc limited ro[ermination noti6ra[ion and <br /> benefit digIbility notificuioa <br /> & Partidpanc account administration aad aarco-bued Faa will be paid [hmugh rhe iedemption of Puticipant ucomt <br /> ahara, unlao agreed upoa othawiu in the Adminisaaave Services Agmmenc <br /> C. Aesignment of benefin is m� pumttted. Benefiq will be paid only w che Participany his/her Survivon, rhe <br /> � Employe , or an inaucance provider (u allowed by tLe daima adminisrramr). Paymenu w an chird P°Y°� <br /> (ag.. medical servia pmvider) are not pecmittcd wirh the aceptina of rcimbumemmt w rhe Employer or inauana <br /> provider (as allowed by [he claima adminiauamr). <br /> D. An eligibk dependmc ie che Partidpanta lewful apouse and any ot6er individual w6o ia a persoa dexribed in IRC <br /> S«tion 152(a), u dariSed by Incemal Revenue Servia Norim 2004-79. <br /> E. The Employer will be naponu1�k for wi�6holdiog, rcpocring and remittinB a�ry appli<abk caaa for paymenrs which <br /> are deeroed m be diaaiminacory under IRC Satioa 105(A), as oudiaed in the VanageCare Retiremwt Hakh <br /> Savings Plan Employer Menual. <br /> ��� RIII•EmP�oyerAeicnowledBmems <br /> A. T6e Employu 6ereby arknowledges ic undersnnda t6at failurc ro propedy fill ouc thu Employr VanugeCare <br /> Retiremmt Hcal[h Savinga Plan Adop[ioo Agrcemmt may result in t6e loss of tu eremption af rhe'Crust and/ar loss <br /> of ra: deferred eraw for Employer coaaibuuona <br /> B. Q Check rhis boz if you arc indadinB �PPocting documenra [hu indude plan provisiom. <br /> EMPLOYBR SIGNATURB � <br /> �� r�,�� iS_� � X D�: /I- O 3/ I <br /> /� . <br /> Titk: l'. 1� r mn �n i� a�P,i/� <br /> � Attate Date: <br /> Tide� <br /> Accepced: VANl}�GEPOINT7RANSFERAGENTS, LLC <br /> � ���� <br /> nasicmn� seaemiy; tcMn-xc � <br /> / <br /> \ � a. i � .�., } �. � � �,. �. �: a. a ' �. y� f <br /> � ^"� fii��1k'Mf� ��� �e �Nd " S t � � T6"a' T'":'']���".�t„y£v�..T``���� (�CS'� '" � ,ffi` i�+3��� .m <br /> �� �y�S•` t � i" � � � j �i�''�yt '`n £ `�� }�`4 Z su'� � *" ��'� ' � t 2� i ` � � � p'+a a 13' 4�.� b*"i il� '..F.i ��� 5� <br /> w`ro `z f r ' .- a TM+_ e, � s, �,�, � yt i w� �b �^ �.�^d a k I- v r Y'r`s,'F¢ ' ��'n�� r.i'o-x ` i , �+'�LQ` ` `k�v ` k.� <br /> -�4-.:,r a� _-? _ ° ..,,,_,._].,.,,. {.? tf _'�a_*. �rn �...�, ..�..�+.....,. , ; �...i " � S .. }� ^ � �',:°! <br /> ti <br /> ,.a_.f.�a _..F �Y. >� ....1.....v?'JT_& ✓? ? t" . _ <br />