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HomeMy WebLinkAboutAdoption Agreement Post-PPA 2022 ________________________________________________________________________________ ADOPTION AGREEMENT FOR THE RUDD & COMPANY PLLC PRE-APPROVED DOCUMENT 20-001 ________________________________________________________________________________ DEFINED CONTRIBUTION PRE-APPROVED ADOPTION AGREEMENT NON-STANDARDIZED ALTERNATIVE ONE: CASH OR DEFERRED PROFIT SHARING PLAN Note: Section references are to the Plan or the Trust. All capitalized terms are defined in the Plan or Trust. All dates are entered in the MM/DD or MM/DD/YYYY format, as applicable. The Rudd & Company PLLC Pre-Approved Adoption Agreement Defined Contribution Plan is hereby adopted by City of Rexburg (the "Employer"). The Plan shall be known as: City of Rexburg Salary Reduction Plan the "Plan". A. General Plan Information Employer Information A1. Employer Address: 35 N. 1st East , Rexburg, ID 83440 A2. Employer Telephone: (208) 359-3020 A3. Employer Tax ID (EIN): 82-6000250 A4. Employer Fiscal Year End: 12/31 A5. Legal Organization of Employer: a.Sole Proprietorship b.Partnership c.C Corporation d.S Corporation e.Limited Liability Company (LLC) f.Limited Liability Partnership (LLP) g.Not for Profit Corporation h.Professional Service Corporation i.Other (Must be legal entity recognized under federal income tax laws.): City (governmental) A6. Business Code (as used on Form 5500; 6-digit NAICS): __________ A7. State of Legal Construction: Idaho A8. Date Business Commenced: ___/___/_____ A9. Members of a Controlled Group or Affiliated Service Group (select all that apply): a. Controlled Group (List controlled group members.): __________ b. Affiliated Service Group (List affiliated service group members.): __________ Note: This list is optional and for informational purposes only. Controlled Group and Affiliated Service Group members who are also Participating Employers will sign this Adoption Agreement, a separate Adoption Agreement, or a Participating Employer Agreement. Plan Information A10. Three Digit Plan Number: 001 -1- A11. Plan Agent: Name: City of Rexburg Address: 35 N. 1st East City: Rexburg State: ID Zip: 83440 Phone: (208) 359-3020 A12. Plan Administrator: Name: City of Rexburg Address: 35 N. 1st East City: Rexburg State: ID Zip: 83440 Phone: (208) 359-3020 A13. Plan Administrator ID Number: 82-6000250 A14. IRS Determination Letter Date (Leave blank for a new plan.): __________ A15. IRS File Folder Number (Leave blank for a new plan.): N/A Trust Information A16. Plan Trustee(s)  Not applicable, the Plan is funded solely by Insurance Contract(s). Name:Jerry L. Merrill Address: 35 N 1st East City: Rexburg State: ID Zip: 83440- Phone: (208) 359-3020 Name:Matthew Nielsen Address: 35 N 1st East City: Rexburg State: ID Zip: 83440- Phone: (208) 372-2343 A17. Trust ID Number: 82-6033935 A18. The Trustee(s) must sign the Adoption Agreement, discretionary amendments, and interim amendments. a.  No b.  Yes Note: An executed copy of the Trust Agreement must be attached to this Plan. The Plan and Trust Agreement must be read and construed together. The powers, rights, and responsibilities of the Trustee shall be those specified in the Trust Agreement. A19. If there are two or more Trustees appointed, they will be bound by the following (select one). a.  Not applicable. b.  The act of a majority of the Trustees. c.  The act of __________ individuals act in the capacity of Trustee. -2- Participating Employers A20. Participating Employers and Multiple Employer Plan (select one). a.  This Plan is not a Multiple Employer Plan and no Related Employers are adopting the Plan. b.  The Employer is the Lead Sponsor of a Plan that includes Participating Employers. If there are Participating Employers who are not Related Employers, this Plan is a Multiple Employer Plan under Code sec. 413(c). c.  The Employer is a Participating Employer in the Plan. The Lead Sponsor is __________. Note: Participating Employers will need to sign this Adoption Agreement, a Participating Employer Agreement, or a separate Adoption Agreement. B. General Plan Features Effective Dates B1. Effective Dates a.The Effective Date of the Plan is: January 1, 2022. Note: May not be earlier than the first day of the initial Plan Year or for restatement of an existing plan, the first day of the current Plan Year. b. Special Effective Dates. The following dates will replace the Effective Date for the Plan provision provided (select one). 1.  Not Applicable 2.  The following special Effective Dates will apply (select all that apply): A.  Pre-Tax Elective Deferrals: ___/___/_____ B.  Roth Elective Deferrals: ___/___/_____ C.  Safe Harbor Contributions: ___/___/_____ D.  Matching Contributions: ___/___/_____ E.  Non-Elective Contributions: ___/___/_____ F.  ___________________________________: ___/___/_____ Note: The date(s) entered may not be earlier than the Effective Date of the Plan. Note: The effective date for Elective Deferrals and Safe Harbor Contributions must be on or after the Adoption Date of the Plan. Note: Safe Harbor Contributions and Roth Elective Deferrals cannot be effective before Pre-Tax Elective Deferrals are effective. c.Initial Effective Dates (select one). 1.  Not applicable, this is a new Plan. 2.  The Plan was initially effective: July 1, 1985. d.Restatement (select one). 1.  Not applicable, this is a new Plan. 2.  This Plan Document is an optional amendment of a pre-existing plan. 3.  This Plan Document is a mandatory restatement of a pre-existing plan. e.Frozen Plan 1.  Not Applicable 2.  The Plan is/was frozen effective: ___/___/_____ Note: No new Participants will enter the Plan and no benefits will accrue to any existing Participant, on or after the date the Plan has been frozen. -3- Contributions B2. Contributions (Select one for each contribution source.) Not Permitted Permitted Formerly Permitted Date Removed a.Pre-Tax Elective Deferrals    ___/___/_____ b.Roth Elective Deferrals    ___/___/_____ c.Voluntary After-Tax Contributions    ___/___/_____ d.Safe Harbor Contributions    ___/___/_____ e.Matching Contributions    ___/___/_____ f.Non-Elective Contributions    ___/___/_____ g.Prevailing Wage Contributions   ___/___/_____ B3. SIMPLE 401(k) a.The Plan intends to meet the requirements to be a SIMPLE 401(k) Plan (select one). 1.  No. 2.  Yes. b.Employer Contribution (select one). 1. A Matching Contribution equal to 100% of each Participant's Elective Deferral up to 3% of SIMPLE Compensation. 2. A Non-Elective Contribution of 2% of a Participant’s SIMPLE Compensation, to be allocated to all Eligible Employees who received at least $ _______ (must be less than $5,000) of SIMPLE Compensation for the Year. Note: If option a.1. is selected skip question b. B4. Deemed IRA a.Deemed IRAs are permitted (select one). 1.  No. 2.  Yes. b.Pre-tax and/or after-tax Roth Deemed IRAs are permitted (select all that apply). 1.  Pre-tax IRA 2.  Roth IRA Note: If option a.1. is selected skip question b. Note: In order to accept a rollover from a Roth IRA, the Plan must permit Deemed IRAs. C. Eligibility C1. Excluded Classes of Employees The classes of Employees specified below will not be eligible to be a Participant in the Plan (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.No exclusions      b.The following exclusions will apply (select all that apply):     1.Union Employees      2.Non-Resident Aliens      3.Employees acquired in a Code section 410(b)(6)(C) transaction N/A N/A N/A N/A 4.HCEs      5.Key Employees      6.Leased Employees      7.HCEs who are Key Employees      8.Self-Employed Individuals      9.Compensation is based solely on commissions      10.Employees not covered by a CBA with the specified unions.     Specify the unions (e.g., ABC Union). -4- A.All contribution sources: ________________________________________ B.Elective Deferrals: ________________________________________ C.Safe Harbor Contributions: ________________________________________ D.Matching Contributions: ________________________________________ E.Non-Elective Contributions: ________________________________________ 11.Other exclusion      Specify the other exclusions (e.g. John Smith, Employees in Division A). A.All contribution sources: ________________________________________ B.Elective Deferrals: ________________________________________ C.Safe Harbor Contributions: ________________________________________ D.Matching Contributions: ________________________________________ E.Non-Elective Contributions: ________________________________________ Note: The exclusions selected cannot result in the group of NHCEs participating under the Plan being only those NHCEs with the lowest amount of compensation and/or the shortest periods of Service and who may represent the minimum number of these Employees necessary to satisfy coverage under Code section 410(b). Note: Selection of any options other than a, b1, b2, b3, or b4 will result in the plan having to satisfy coverage testing under Code section 410(b). Note: The definition of "other exclusion" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. Note: The definition of “other exclusion” cannot result in an exclusion based on age or length of service or create an indirect service requirement. C2. QACA Excluded Classes of Employees If the Plan includes a QACA provision, Employees with an affirmative Elective Deferral election are excluded from the Plan for Safe Harbor Contribution purposes (select one). a.  No b.  Yes C3. Age Requirement for Eligibility Employees must be at least __ years of age to be eligible to participate in the Plan (select one for each applicable source). All contribution sources Not Applicable ____ Elective Deferrals Not Applicable 21.0 Safe Harbor Contributions Not Applicable ____ Matching Contributions Not Applicable 21.0 Non-Elective Contributions Not Applicable 21.0 Note: Age cannot be greater than age 21. If the Plan is maintained exclusively for employees of a Code section 170(b)(a)(A)(ii) educational institution and Participants are 100% vested no later than upon attainment of one Year of Vesting Service, the age can be no greater than 26. C4. Service Requirement for Eligibility Employees who meet the service requirements specified below during the Eligibility Computation Period will be eligible to participate in the specified portion of the Plan (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.No service required      b.One Year of Eligibility Service      c.Two Years of Eligibility Service N/A N/A N/A   d.__ months of Eligibility Service      ___6 ___6 6 e.___ consecutive months of Eligibility Service      _______________ f.___ Years of Eligibility Service with ___ Hours of Eligibility Service in each year      ___\_______\_______\_______\_______\____ -5- g.___ months of Eligibility Service with ___ Hours of Eligibility Service in each month      ___\_______\_______\_______\_______\____ h.Other service requirement      Specify the other service requirement (e.g. 6 consecutive months of service with 500 hours of service earned over the 6-month time frame). 1.All contribution sources: ________________________________________ 2.Elective Deferrals: ________________________________________ 3.Safe Harbor Contributions: ________________________________________ 4.Matching Contributions: ________________________________________ 5.Non-Elective Contributions: ________________________________________ Note: The Years of Eligibility Service required cannot exceed 1 year of service for Elective Deferrals and Safe Harbor Contributions and 2 years for Matching Contributions and Non-Elective Contributions. If more than 1 year of service is required for Matching Contributions or Non-Elective Contributions, the applicable contribution source must be 100% vested at two Years of Eligibility Service. Note: The months of service required cannot exceed 12 months of service for Elective Deferrals and Safe Harbor Contributions and 24 months of service for Matching Contributions and Non-Elective Contributions. If more than 12 months of service are required for Matching Contributions or Non-Elective Contributions the applicable contribution source must be 100% vested at 24 months of Eligibility Service. Note: The definition of "other service requirement" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. Note: Hours of service failsafe: Regardless of the election made above, if eligibility is determined using the hours of service method, an Employee will be deemed to meet the eligibility requirement no later than the end of an Eligibility Computation Period during which the Employee completes 1,000 Hours of Eligibility Service; provided, that the individual is an Eligible Employee on the applicable entry date. C5. For service requirements that include an hours requirement a Participant will have met the service requirement at the following time (select one). As soon as they have met the service requirement regardless if the entire period has passed. At the end of the measurement period in which the service requirement was met. a.All contribution sources   b.Elective Deferrals   c.Safe Harbor Contributions   d.Matching Contributions   e.Non-Elective Contributions   C6. Prevailing Wage Eligibility - Excluded Classes Prevailing Wage Contributions will have no age or service requirements and will have immediate entry dates. The following Participants will be excluded from receiving Prevailing Wage Contributions (select all that apply). a.No excluded classes. b.The following Participants will be excluded (select all that apply): 1.HCEs. 2.Other: __________. Note: The “Other” excluded classes must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -6- C7. One-Time Election A Participant may make a one-time election pursuant to Plan Section 2.1.6 to not become a Participant under the Plan (select one). a.No. b.Yes. Measuring Service C8. Year of Eligibility Service The Method of Measuring a Year of Eligibility Service is the following (select one). a.Not applicable, there are no service requirements for any source under the Plan. b. Hours of service method. A Year of Eligibility Service is _______ hours (not more than 1,000) in the Eligibility Computation Period. c.Elapsed time method. Note: If option b is not selected skip questions C9 – C10. If option a is selected skip question C11. C9. Eligibility Computation Period If the hours of service method is selected above, the first Eligibility Computation Period is the 12-month period ending on the first anniversary of the Employee’s Employment Commencement Date. Subsequent Eligibility Computation Periods will be measured as follows (select one). a. It will remain a 12-month period based on the anniversary of the Employee’s Employment Commencement Date. b. It will switch the Plan Years beginning with the first Plan Year commencing prior to the first anniversary of the Employee’s Employment Commencement Date. C10. Break in Eligibility Service If the hours of service method is selected above, a Break in Eligibility Service occurs if an Employee fails to complete ____ (not more than 500) Hours of Service in an Eligibility Computation Period. Note: If actual hours are being used and no Hours of Service are completed then a Break in Service will be defined as the lesser of 500 hours or the number of Hours of Service needed to earn a Year of Eligibility Service. C11. Equivalencies a. Hours of Service If the hours of service method is selected above, when records of hours are not maintained the following equivalency will apply (select one). 1.Not applicable, actual hours will be used for all Employees. 2.The following equivalency will apply (select one). A.Days worked (10 hours) B.Weeks worked (45 hours) C.Semi-Monthly or Bi-weekly Payroll period worked (95 hours) D.Months worked (190 hours) b. Elapsed Time If the elapsed time method is selected above, eligibility service will be measured using the following (select one). 1.The exact date in years. 2.The exact date in months. 3. Calendar months with Employee granted a month of service if they work at least one Hour of Service in that month. 4.The nearest calendar month. 5.Completed calendar months. -7- C12. Service with Predecessor and Prior Employers Service with Predecessor Employers must be treated as service for the Employer if the Employer maintains the plan of the Predecessor Employer. In all other cases, service with a Predecessor Employer or a Prior Employer is granted as specified below. a.Predecessor or Prior Employer Service (Select one.) 1.No service with a Predecessor or Prior Employer will be credited. 2.Service with a Predecessor or Prior Employer is credited as specified below. A. Service with the following entities shall be credited as service under this Plan: ________________________________________ B. Service with the above entities has been determined under the terms of the following documents, if any: ________________________________________ b. Service with a Predecessor or Prior Employer will be credited for the following purposes (select all that apply): 1.Eligibility Service. 2.Vesting Service. 3.Contribution Allocations. 4.Attainment of Early or Normal Retirement Age. c. Service with a Predecessor or Prior Employer will be limited as follows: ________________________________________ C13. Age and Service Waiver a.The age and service requirements will be waived as specified below (select one). 1.Not applicable 2.For all contribution sources 3.For the following contribution sources (select all that apply). A.Elective Deferrals B.Safe Harbor Contributions C.Matching Contributions D.Non-Elective Contributions E. Other (e.g., Prevailing Wage Contributions): __________ b.The age and service requirements will be waived for Employees Employed on ___/___/_____ c.The following requirements will be waived (select all that apply). 1.The age requirement. 2.The service requirement. d.Employees subject to the waiver will enter the Plan on (select one): 1.The Effective Date of this document. 2.The next Plan Entry Date for the applicable contribution source. 3. Other (e.g., specific date): __________ (date must be prior to next Plan Entry Date). e.The following limitations will apply to the age and/or service waiver (select one). 1.No limitations. 2. Other (e.g., only Employees hired due to merger with Acme Inc. will be subject to the waiver): __________ Plan Entry C14. Entry Dates Employees who meet the service requirements specified during the Eligibility Computation Period will be eligible to participate in the specified portion of the Plan (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions -8- a. Daily      b. Weekly on the ___(e.g., first)      day of the week ____ ____ ____ ____ ____ c. Monthly on the ___(e.g., last)      day of the month ____ ____ ____ ____ ____ d. Quarterly starting on __/__      day of the month __/__ __/__ __/__ __/__ __/__ e. Semi-annually starting on __/__      __/__ __/__ __/__ __/__ __/__ f. First Day of the Plan Year      g. Last Day of the Plan Year      h. Anniversary Date of the Employee's hire date      i. Other Entry Date(s)      Specify the other Entry Dates (e.g. payroll date). 1. All contribution sources: ________________ 2. Elective Deferrals: ________________ 3. Safe Harbor Contributions: ________________ 4. Matching Contributions: ________________ 5. Non-Elective Contributions: ________________ Note: If option a is selected for any contribution source skip question C15 for that contribution source. C15. Entry Time Employees will be eligible to participate in the specified portion of the Plan on the Entry Date __________ the date they meet the eligibility requirements specified for the contribution source (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.coincident with or next following      b.next following      c.nearest to N/A N/A N/A   C16. Special Entry Dates In addition to the Entry Dates specified above the following dates will also be Entry Dates (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.Not Applicable      b.Special Entry Date(s)     Specify the special Entry Dates (e.g. 2/1/2018). 1.All contribution sources: ________________________________________ 2.Elective Deferrals: ________________________________________ 3.Safe Harbor Contributions: ________________________________________ 4.Matching Contributions: ________________________________________ 5.Non-Elective Contributions: ________________________________________ Note: The special Entry Dates must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. D. Dates and Definitions General Dates D1. Plan Year a.The Plan Year (must be 12 consecutive months.) 01/01 to 12/31. b.The Plan has a short Plan Year of: ___/___ to ___/___. -9- D2. Limitation Year The Limitation Year is the (select one): a.Plan Year. b.calendar year coinciding with or ending within the Plan Year. c.12 consecutive month period ending __/__. d.Employer’s Fiscal Year ending with or within Plan Year. e.12 consecutive month period ending __________ (e.g., the last Friday in February) with or within Plan Year. D3. Anniversary Date The Anniversary Date is (select one): a.the last day of the Plan Year. b.the first day of the Plan Year. c. __/__ of each Plan Year. d.other (must be at least annually): _____ D4. Valuation Date The Valuation Date is the (select all that apply): a.Last day of the Plan Year b.Semiannually c.Quarterly d.Monthly e.Daily f. Other (i.e., assets held in XYZ fund will be valued on the 15th day of each calendar month, must be at least annually): __________ Retirement Age D5. Normal Retirement Age (NRA) For each Participant the Normal Retirement Age is (select all that apply): a.The later of age 65 or the 5th anniversary of participation in the Plan (statutory). b.Age 65. c.Age ____ and ____ Years of Service. d.Age ____ and ____ Years of Participation. e.Age ____ and the ____ anniversary of actual participation in the Plan. f. Other: __________ , but in no event later than the later of age 65 or the 5th anniversary of participation. Note: The age specified must be at least 55 and cannot exceed 65. If an age less than 62 is specified, the IRS Opinion Letter cannot be used to show that the age is reasonably representative of the typical retirement age for the industry in which the Participants work. Note: The service specified cannot be greater than 5 years. Note: If more than one option is selected, NRA is attained on the first date the requirements of any option are met, but in no event later than age 65 and the 5th anniversary of participation in the Plan. For this purpose only, participation is assumed to commence as of the first day of the first Plan Year in which the Employee became a Participant. Note: The definition of "Normal Retirement Age" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -10- D6. Normal Retirement Date The Normal Retirement Date is (select one): a.The actual date NRA is attained. b.The first day of the month in which NRA is attained. c.The first day of the month nearest the date NRA is attained. d.The first day of the month coincident with or next following the date NRA is attained. e.Anniversary Date nearest the date NRA is attained. f.Anniversary Date coincident with or next preceding the date NRA is attained. g.The last day of the month in which NRA is attained. h.Other (e.g., The last day of the month nearest the date NRA is attained): __________ D7. Early Retirement Age (ERA) For each Participant, the Early Retirement Age is (select all that apply): a.The Plan does not provide an ERA. b.Age ___. c.Age ____ and ____ Years of Service. d.Age ____ and ____ Years of Participation. e.Age ____ and the ____ anniversary of actual participation in the Plan. f. Other (e.g., Age 55 and the fifth anniversary of employment): __________ Note: If option a is selected skip question D8. Note: In no event shall ERA exceed NRA. Note: If more than one option is selected, the Participant attains ERA at the earliest age when any of the selected requirements are satisfied. Note: The definition of "Early Retirement Age" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. D8. Early Retirement Date The Early Retirement Date is (select one): a.The actual date ERA is attained. b.The first day of the month in which ERA is attained. c.The first day of the month nearest the date ERA is attained. d.The first day of the month coincident with or next following the date ERA is attained. e.Anniversary Date nearest the date ERA is attained. f.Anniversary Date coincident with or next preceding the date ERA is attained. g.The last day of the month in which ERA is attained. h. Other (e.g., The last day of the month nearest the date ERA is attained): __________ General Definitions D9. Highly Compensated Employee (HCE) Determination a.HCEs will be determined using the top-paid group election (select one). 1.No 2.Yes b.HCEs will be determined using the calendar year data election (select one). 1.No 2.Yes c.When determining HCEs, Compensation will be measured over the following period (select one). 1.The preceding Plan Year. 2. The calendar year beginning within the preceding Plan Year (non-calendar year plans only). 3. The 12-month period ending __/__. (Select this option when using the Plan Year of another plan of the Employer.) -11- D10. Disability An Employee or Participant has a "Disability" and is “Disabled” if (select all that apply): a. No disability benefits are provided and there are no disability-related vesting or waiver provisions. b. The Participant suffers from a medically determinable physical or mental impairment that may be expected to result in death or to last for a continuous period of not less than 12 months and that renders him incapable of performing his duties. c. The Social Security Administration has determined that the Participant is eligible to receive Social Security disability benefits. d. The Participant has begun to receive payments under the long-term disability program or a comparable disability program maintained by the Employer. e.Other: _____. Note: If more than one option is selected, a Participant is Disabled on the first date the requirements of any option are met. Note: The definition of "Disability" provided must be objectively determinable and may not be specified in a manner that is subject to Plan Administrator discretion. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. D11. Designated Beneficiary a. Default Beneficiary In the event the Participant does not have a valid Designated Beneficiary, the Designated Beneficiary will be (select one): 1.determined under Plan Section 3.6.2. 2.the Participant’s spouse; if no spouse, the Participant’s estate. 3. other (e.g., the Participant’s spouse; if no spouse the Participant’s children; if no children the Participant’s estate): _________ Note: If the Plan is a REA safe harbor plan the Participant’s spouse must be the first default Designated Beneficiary. b. Expiration of Beneficiary Designation A Participant’s valid beneficiary designation will expire when (select one): 1.designations will never expire. 2. upon divorce the ex-spouse shall be treated as having predeceased the Participant unless a beneficiary designation is completed post-divorce naming the ex-spouse as a Beneficiary. 3. other (e.g., marriage of the Participant): __________ Note: A Beneficiary designation cannot expire upon legal separation. c. One-Year Marriage Rule The One Year Marriage rule will apply (select one): 1.No. 2.Yes. E. Compensation E1. Base Definition A Participant's Compensation is based on (select one for each applicable source): All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.W-2 Compensation      b.3401(a) Compensation      c.415(c)(3) Compensation      d.Simplified 415 Compensation      Exclusions From Compensation E2. Exclusion of Deferrals The selected deferrals will be excluded from the definition of Compensation for the purposes specified (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions -12- a.All of the items listed below.     b.The following items (select all that apply):     1.125 (Cafeteria Plan)     2.132(f)(4) (Transportation)     3.402(e)(3) (401(k) and 403(b) deferrals)     4.402(h)(1)(B) (Sep deferrals)     5.408(p) (Simple Retirement Account 402(k) deferrals)     6.457(b) deferrals      Note: All salary deferrals must be included or excluded to maintain a Code sec. 414(s) safe harbor definition of Compensation. Exclusion of less than the full list will necessitate testing under Code section 414(s) to ensure the definition of Compensation is not discriminatory for all sources other than Elective Deferrals. Note: If the item is not selected it will be included in the definition of Compensation for the applicable contribution source. E3. Non-Participating Non-Resident Aliens Provided the compensation is excluded from gross income and not effectively connected with a U.S. trade or business, compensation paid to nonresident aliens who are not Participants will be excluded from the definition of Compensation (select one). a.No. b.Yes. E4. Other Exclusions The selected items will be excluded from the definition of Compensation for the purposes specified (select one for each applicable source). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.No other exclusions      b.The following items (select all that apply):     1.Overtime      2.Commissions      3.Discretionary bonuses      4.Bonuses      5.Taxable employee benefits      6.Compensation paid by an Employer who is not a Participating Employer      7.In excess of      A. Specify dollar amount: $___ $___ $___ $___ $___ 8.Other exclusion      Specify the other exclusions (e.g. compensation earned under a prevailing wage agreement). A. All contribution sources: _____ B. Elective Deferrals: _____ C. Safe Harbor Contributions: _____ D. Matching Contributions: _____ E. Non-Elective Contributions: _____ Note: The definition of "other exclusion" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. Note: Any exclusion in this section aside from taxable employee benefits will necessitate testing under Code section 414(s) to ensure the definition of Compensation is not discriminatory for all sources other than Elective Deferrals. Inclusions in Compensation E5. Other Inclusions The selected items will be included in the definition of Compensation for the purposes specified (select one for each applicable source). -13- All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.No other inclusions      b.The following items (select all that apply):     1.Earned before entry date      2.Deemed 125 Compensation      3.Post Year End Compensation      4.Post-Severance Compensation      5.Differential Wage Payments      6.Military Continuation Payments      7.Unfunded Deferred Comp Plan      8.Other inclusion:     Specify the other inclusions (e.g. compensation earned under a prevailing wage agreement): A.All contribution sources: _____ B.Elective Deferrals: _____ C.Safe Harbor Contributions: _____ D.Matching Contributions: _____ E.Non-Elective Contributions: _____ Note: The definition of "other inclusions" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. Note: Elections made for items a, b1, b2, or b3 do not affect the 414(s) safe harbor status of the Plan’s definition of Compensation. Other Compensation E6. Salary Continuation for Disabled Participants Salary paid to Participants who are disabled is (select one for each applicable source): All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.Excluded.     b.Included for all Participants.     c.Included for all Participants who are not HCEs.     E7. Compensation Computation Period The Compensation Computation Period is the following period that ends with or within the Plan Year (select one for each applicable purpose). All Contrib. Sources Elective Deferrals Safe Harbor Contributions Matching Contributions Non-Elective Contributions a.Plan Year      b.Limitation Year      c.Calendar year      d.Pay period      e.Monthly period      f.Quarterly period      g.Semi-Annually      h.Bi-Weekly      i.Weekly period      j.The 12-consecutive month period ending on __/__     1.Specify the date: ____ ____ ____ ____ ____ Note: The Compensation Computation Period for Safe Harbor Non-Elective Contributions is the Plan Year. Note: If option j is selected, for Employees whose Employment Commencement Date is less than 12 months before the end of the 12-month period designated, Compensation will be determined over the Plan Year. -14- E8. Prevailing Wage Compensation Compensation for Prevailing Wage Purposes will be defined the same as Compensation for (select one): a.Elective Deferrals. b.Safe Harbor Contributions. c.Matching Contributions. d.Non-Elective Contributions. e.As specified on the Prevailing Wage Addendum. E9. Code Section 415 and 416 Compensation a.For the purposes of Code section 415 and 416, Compensation will be defined as (select one): 1.W-2 Compensation. 2.3401(a) Compensation. 3.415(c)(3) Compensation. 4.Simplified 415 Compensation. b.For the purposes of Code section 415 and 416, the selected items will be included in the definition of Compensation (select all that apply). 1.Deemed 125 Compensation 2.Post Year End Compensation 3.Post-Severance Compensation 4.Differential Wage Payments 5.Military Continuation Payments 6.Unfunded Deferred Compensation Plan 7.Nonparticipating Nonresident Aliens salary 8.Other Inclusion (e.g., PTO Payments): _____ Note: The definition of "other inclusions" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. c.For the purposes of Code section 416, salary paid to Participants who are disabled is (select one): 1.Excluded. 2.Included for all Participants. 3.Included for all Participants who are not HCEs. F. Elective Deferrals, Voluntary After-Tax Contributions, and Safe Harbor Contributions Elective Deferrals F1. Limitations a.Minimum deferral election (select one): 1.No minimum deferral. 2.The following minimum deferral (select all that apply): A.Elective Deferrals must be at least 1 % of Compensation. B.Elective Deferrals must be at least $ ____ per payroll period. b.Maximum deferral election (select one): 1.Not applicable. 2.The following maximums (select all that apply): A.Elective Deferrals cannot exceed ____ % of Compensation. B.Elective Deferrals cannot exceed $ ____ per Plan Year. C.HCE's Elective Deferrals cannot exceed $ ____ per Plan Year. D.HCE's Elective Deferrals cannot exceed ____ % of Compensation. c.Other limitations on Elective Deferrals (select one): 1.Not applicable. 2. _____. Note: The other limitations provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -15- F2. Catch-up Contributions Catch-up Contributions are permitted (select one). a.No. b.Yes. F3. Roth Elective Deferrals If Roth Elective Deferrals are permitted under the Plan, Participants (select one): a.can elect to defer both Pre-Tax Elective Deferrals and Roth Elective Deferrals. b.must elect to defer either Pre-Tax Elective Deferrals or Roth Elective Deferrals. Automatic Enrollment F4.The following automatic enrollment provisions will apply to the Plan (select one): a.Not applicable. b.Automatic Contribution Arrangement (ACA). c.Eligible Automatic Contribution Arrangement (EACA). d.Qualified Automatic Contribution Arrangement (QACA). Note: If option a. is selected, skip questions F5 – F7. Note: If QACA is chosen the Safe Harbor Contribution section must be completed. F5. Automatic Deferral Rates a.The automatic deferral rate for an ACA or EACA will be (select one): 1.a flat deferral rate of ____ %. 2. an increase deferral rate starting at ___% and increasing by ____% on each Increase Date after the Initial Period to a maximum default deferral rate of ____%. 3.a deferral rate that varies by Participant group. (See EACA Addendum.) 4. Other (e.g., $25 per payroll period): _____ b.The automatic deferral rate for a QACA will be (select one): 1. a flat deferral rate of __% (must be at least 6 and no more than 10%). 2. the QACA statutory provisions of an increase deferral rate starting at 3% and increasing by 1% on each Increase Date after the Initial Period to a maximum default deferral rate of 6%. 3. an increase deferral rate starting at __% and increasing by __% on each Increase Date after the Initial Period to a maximum default deferral rate of __%. Note: If option 3. is selected the initial deferral rate must be at least 3%, the increase must be at least 1% and the maximum deferral rate cannot be greater than 10%. F6. Increase Date and Initial Period a. If the automatic enrollment provision includes increasing deferral rates the Increase Date will be (select one): 1.the first day of the Plan Year. 2.Other (e.g., July 1, the anniversary of the Participant's date of hire): _____. b.A Participant’s Initial Period will end (select one): 1.on the first Increase Date following the start of default deferrals under the Plan. 2. on the first Increase Date following the first full Plan Year of default deferrals under the Plan. -16- F7.The following Participants are subject to the default elections (select one): a.all Participants. b.the following Participants (select all that apply): 1.current Participants without an election. 2.all Participants whose prior year election is less than the initial default deferral rate. 3.all Participants hired after __/__/__. 4. the selections above apply only to Participants who do not have an election on file on or after __/__/__. Under a 401(k) plan, the plan may provide that an affirmative election expires annually. If a Participant fails to complete a new affirmative election subsequent to their prior election expiring, the Participant becomes subject to the default deferral percentage as outlined in the plan pursuant to the automatic contribution provision. Each year, the Participant can always complete a new affirmative election and designate a new deferral percentage. Note: An election not to defer must be on file. In-Plan Roth Rollover F8.In-Plan Roth Rollovers are permitted (select one): 1.No. 2.Yes, provided the Participant is eligible to take a distribution under the terms of the Plan. 3. Yes, provided the Participant is eligible to take a distribution under the Code and Treasury Regulations regardless of the terms of the Plan. 4.Yes. Note: The Plan must allow for Roth Elective Deferrals in B2.b in-order to allow for In-Plan Roth Rollovers. F9.In-Plan Roth Rollovers are permitted from the following Accounts (select one). a.All non-Roth Accounts under the Plan. b. Other contributions (e.g., Rollover Contributions): _____. F10. Limitations In-Plan Roth Rollovers are limited by (select one): a.No limitations. b.The following limitations (select all that apply): 1.Account must be fully vested. 2. Other (e.g., only one In-Plan Roth Rollover per Plan Year): _____. Voluntary After-Tax Contributions F11. Voluntary After-Tax Contributions are limited to (select one): a.No Plan limitations. b.The following limitations (select all that apply): 1. Voluntary After-Tax Contributions cannot exceed ____% of Compensation per Plan Year. 2.Voluntary After-Tax Contributions cannot exceed $ _____ per Plan Year. -17- Safe Harbor Contributions F12. ADP Safe Harbor Contributions The Plan will make the following ADP Test Safe Harbor Contributions to Participants eligible to receive Safe Harbor Contributions (select one): a.Traditional Basic Matching Contribution 100% of the Elective Deferral that does not exceed 3% of Compensation, plus 50% of the Elective Deferral that exceeds 3% of Compensation but does not exceed 5% of Compensation. b.QACA Basic Matching Contribution 100% of the Elective Deferral that does not exceed 1% of Compensation, plus 50% of the Elective Deferral that exceeds 1% of Compensation but does not exceed 6% of Compensation. c.Enhanced Matching Contribution ____% of the Elective Deferral that does not exceed ____% of Compensation, plus ____% of the Elective Deferral that exceeds ____% of Compensation but does not exceed ____% of Compensation. d. Other ADP Test Safe Harbor Matching Contribution (e.g., 100% of Elective Deferrals that exceeds 8% for non-HCEs and 100% of Elective Deferrals that exceeds 5% for HCEs). __________ e.ADP Test Safe Harbor Non-Elective Contribution at least ____ % of Compensation (must be at least 3%). Note: If c or d is chosen the selection must be completed so that the Safe Harbor Contribution the Participant will receive at each deferral level is at least as good as they would receive under the applicable basic matching contribution. Note: Option b cannot be chosen if the Plan has elected the traditional safe harbor provisions. Note: In order to be covered by the IRS pre-approval letter, the other ADP Safe Harbor Matching Contribution formula must be a combination of Matching Contribution formulas available in this Plan Document. Any other formulas will not be covered by the IRS pre-approval letter. F13. ADP Safe Harbor Contributions will be made to (select one): a.this Plan. b. another plan of the Employer: _____. Note: If option b is selected the full name of the other Employer plan must be completed. The other Employer plan must have the same Plan Year, safe harbor contributions, and eligibility for safe harbor contributions as this Plan. -18- F14. ACP Safe Harbor Contributions While no further contributions are required to meet the Safe harbor Contribution requirements, Participants eligible to receive Safe Harbor Contributions may receive (select one): a.ACP Safe Harbor Contributions will not be made to the Plan. b.The following ACP Safe Harbor Contributions (select all that apply): 1. the Plan may choose to make a discretionary ACP Safe Harbor Contribution. If a discretionary ACP Safe Harbor Matching Contribution formula applies (i.e., a formula that provides an Employer with discretion regarding how to allocate a Matching Contribution to Participants) and the Employer makes a discretionary ACP Safe Harbor Matching Contribution to the Plan, the Employer must provide the Plan Administrator (or Trustee, if applicable), written instructions describing (1) how the discretionary ACP Safe Harbor Matching Contribution formula will be allocated to Participants (e.g., a uniform percentage of Elective Deferrals or a flat dollar amount); (2) the computation period(s) to which the discretionary ACP Safe Harbor Matching Contribution formula applies; and (3) if applicable, a description of each business location or business classification subject to separate discretionary ACP Safe Harbor Matching Contribution allocation formulas. Such instructions must be provided no later than the date on which the discretionary ACP Safe Harbor Matching Contribution is made to the Plan. A summary of these instructions must be communicated to Participants who receive discretionary ACP Safe Harbor Matching Contributions. The summary must be communicated to Participants no later than 60 days following the date on which the discretionary ACP Safe Harbor Matching Contribution is made to the Plan. 2. the Plan will make a mandatory ACP Safe Harbor Contribution in the amount of (select one): A. ____% of Elective Deferrals that do not exceed ____% of Compensation. B. ____% of Elective Deferrals that do not exceed ____% of Compensation, plus ____% of Elective Deferrals that exceeds ____% of Compensation but do not exceed ____% of Compensation. C.other: __________. Note: While no further contributions are required to meet the Safe harbor Contribution requirements, the Plan may elect to make ACP Safe harbor Contributions in addition to the required ADP Safe Harbor Contributions. Note: A discretionary ACP Safe Harbor Contribution cannot exceed 4% of Compensation. Note: An ACP Safe Harbor Contribution cannot be made on Matched Contributions in excess of 6% of Compensation. Note: In order to be covered by the IRS pre-approval letter, the other ACP Safe Harbor Matching Contribution formula must be a combination of Matching Contribution formulas available in this Plan Document. Any other formulas will not be covered by the IRS pre-approval letter. F15. Allocation Dates Safe Harbor Contributions will be allocated as of the (select one for each applicable source): ADP Safe Harbor Contributions ACP Safe Harbor Contributions a.last day of the Plan Year   b.last day of each pay period   c.last day of each Plan quarter   d.last day of each calendar month   e.other:  Specify the other allocation date (e.g., last day of the calendar year). 1.ADP Safe Harbor Contributions: __________ 2.ACP Safe Harbor Contributions: __________ -19- G. Matching Contributions and Non-Elective Contributions Matching Contributions G1. Allocation Conditions In order to be eligible to receive a Matching Contribution, the Participant must (select one): a.No allocation conditions. b.The following allocation conditions will apply (select all that apply): 1.to be employed on the last day of the Plan Year 2.have received Compensation since the prior Allocation Date for Matching Contributions 3.must be employed on the Allocation Date for Matching Contributions 4.must complete the following service requirement: A. ____ (no more than 1,000) Hours of Credited Service in the Plan Year. B. ____ (no more than 365) days using the Elapsed Time method of counting service. C. ____ (no more than 12) months using the Elapsed Time method of counting service. Note: If option a is selected, skip question G2. G2. Allocation Condition Waivers The allocation conditions for Matching Contributions will be waived if, during the Plan Year, a Participant (select one for each applicable allocation condition): All Allocation Last Day Service Conditions Requirement Requirement a.No allocation condition waivers    b.The following waivers apply (select all that apply)   1.dies.   2.becomes Disabled.   3.terminates from service after reaching NRA.   4.is employed on the last day of the Plan Year N/A N/A  5.other event.   Specify the other event (e.g., furloughed longer than 4 weeks): A.All Allocation Conditions: __________ B.Last Day Requirement: __________ C.Service Requirement: __________ Note: The definition of "other events" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. G3. Matched Contributions The following Employee contributions will be included in the definition of Matched Contribution (select all that apply): a.Pre-Tax Elective Deferrals. b.Roth Elective Deferrals. c.Catch-up Contributions. d.Voluntary After-Tax Contributions. e. Other (e.g., Elective Deferrals made under the Employer's 403(b) plan): ________________________________________ Note: The other Matched Contribution specified must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -20- G4. Matching Contribution Formula The amount of the Matching Contributions made on behalf of Participants eligible for Matching Contributions for each Plan Year will be (select one): a. a discretionary amount determined by the Employer in a non-discriminatory manner. If a discretionary Matching Contribution formula applies (i.e., a formula that provides an Employer with discretion regarding how to allocate a Matching Contribution to Participants) and the Employer makes a discretionary Matching Contribution to the Plan, the Employer must provide the Plan Administrator (or Trustee, if applicable), written instructions describing (1) how the discretionary Matching Contribution formula will be allocated to Participants (e.g., a uniform percentage of Elective Deferrals or a flat dollar amount); (2) the computation period(s) to which the discretionary Matching Contribution formula applies; and (3) if applicable, a description of each business location or business classification subject to separate discretionary Matching Contribution allocation formulas. Such instructions must be provided no later than the date on which the discretionary Matching Contribution is made to the Plan. A summary of these instructions must be communicated to Participants who receive discretionary Matching Contributions. The summary must be communicated to Participants no later than 60 days following the date on which the discretionary Matching Contribution is made to the Plan. b.Flat Percentage 50% of Matched Contributions that do not exceed 4% of Compensation. c.Graded Match based on Percentage of Compensation Deferred ____% of Matched Contributions that do not exceed ____% of Compensation, plus ____% of Matched Contributions that exceeds ____% of Compensation but do not exceed ____% of Compensation. d. other Matching Contribution formula specified on the Matching Contribution Formula Addendum. G5. Supplemental Discretionary Matching Contribution Formula The Employer may choose to make a Supplemental Discretionary Matching Contribution on behalf of Participants eligible for Matching Contributions for each Plan Year (select one). a.No. b. Yes. If a discretionary Matching Contribution formula applies (i.e., a formula that provides an Employer with discretion regarding how to allocate a Matching Contribution to Participants) and the Employer makes a discretionary Matching Contribution to the Plan, the Employer must provide the Plan Administrator (or Trustee, if applicable), written instructions describing (1) how the discretionary Matching Contribution formula will be allocated to Participants (e.g., a uniform percentage of Elective Deferrals or a flat dollar amount); (2) the computation period(s) to which the discretionary Matching Contribution formula applies; and (3) if applicable, a description of each business location or business classification subject to separate discretionary Matching Contribution allocation formulas. Such instructions must be provided no later than the date on which the discretionary Matching Contribution is made to the Plan. A summary of these instructions must be communicated to Participants who receive discretionary Matching Contributions. The summary must be communicated to Participants no later than 60 days following the date on which the final discretionary Matching Contribution is made to the Plan for each Plan Year. G6. Limitations Matching Contributions will be limited to (select one): a.No limitations b.The following limitations apply (select all that apply): 1. ____% of Compensation per Plan Year. 2. $____ per Plan Year. 3. $____ per payroll period. 4.other (e.g., 3% of Compensation per Plan Year for HCEs): 4% of Compensation per payroll period Note: The other limitations on Matching Contributions must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -21- G7. Allocation Dates a.Matching Contributions will be allocated as of the (select one): 1. last day of the Plan Year 2. last day of each pay period 3. last day of each Plan quarter 4. last day of each calendar month 5. other (e.g., last day of each calendar quarter): _____ b. If Matching Contributions are not allocated on the last day of the Plan Year, any allocation conditions will be pro-rated. G8. 410(b) Coverage Failure Participants who normally would not be given an allocation of Matching Contributions may be given an allocation in order to satisfy the requirements of Code section 410(b) (select one): a.  No. The Plan must be amended in the case of a failure under Code section 410(b). b.  Yes. The Code section 410(b) fail safe will be used in the case of a failure under Code section 410(b). Non-Elective Contributions G9. Allocation Conditions In order to be eligible to receive a Non-Elective Contribution, the Participant must (select one): a.No allocation conditions. b.The following allocation conditions will apply (select all that apply): 1.be employed on the last day of the Plan Year 2. have received Compensation since the prior Allocation Date for Non-Elective Contributions 3.must be employed on the Allocation Date for Non-Elective Contributions 4.must complete the following service requirement: A. 500 (no more than 1,000) Hours of Credited Service in the Plan Year. B. ____ (no more than 365) days using the Elapsed Time method of counting service. C. ____ (no more than 12) months using the Elapsed Time method of counting service. Note: If option a is selected, skip question G10. G10. Allocation Condition Waivers The allocation conditions for Non-Elective Contributions will be waived if, during the Plan Year, a Participant (select one for each applicable purpose): All Allocation Last Day Service Conditions Requirement Requirement a.No allocation condition waivers    b.The following waivers apply (select all that apply)   1.dies.   2.becomes Disabled.   3.terminates from service after reaching NRA.   4.is employed on the last day of the Plan Year. N/A N/A  5.other event:   Specify the other event (e.g., furloughed longer than 4 weeks): A.All Allocation Conditions: __________ B.Last Day Requirement: __________ C.Service Requirement: __________ Note: The definition of "other events" provided must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion and, may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -22- G11. Non-Elective Contribution Amount Non-Elective Contributions will be made in the following amount (select one): a.a discretionary amount determined by the Employer each Plan Year. b. an amount necessary to meet the requirements of the Non-Elective Contribution allocation formula specified below. c. ____% (no more than 25%) of eligible Plan Compensation. d. $____ per Plan Year, but no more than 25% of eligible Plan Compensation. e. the amount required under any applicable collectively bargained for agreement (CBA). Note: Options b – e are mandatory contributions that must be made every Plan Year. Note: Option b cannot be chosen unless option G12a is chosen or G12i is chosen and the formula specified includes a dollar or percentage amount per Participant. Note: If option e is chosen, the CBA provisions related to the Non-Elective Contribution amount must be included as an addendum to the Plan. G12. Non-Elective Contribution Allocation Formula Non-Elective Contributions will be allocated to Participants eligible to receive a Non-Elective Contribution according to the following formula (select one): a.Flat dollar amount. The allocation will be based on the (select one): 1.Plan Year. 2.Compensation Computation Period. b.Pro-rata. The allocation will be based on the (select one): 1.Plan Year. 2.Compensation Computation Period. c. ____% of Compensation per Participant. d.Age Weighted. 1. Pre-Retirement Interest Rate: ____ (must between 7.5% and 8.5%). 2. Post-Retirement Interest Rate: ____ (must between 7.5% and 8.5%). 3. Post-Retirement Mortality (e.g., UP-84 Unisex): _____. e.Integrated Formula. (Complete Question G13.) f.Uniform Points. (Complete Question G14.) g.Class Allocation based on each Participant in an individual group. h.Class Allocation based on defined groups. (Complete Question G15.) i. Other (e.g., the greater of $500 or 1% of Plan Year Compensation): _____. Note: Options a - e are design based safe harbor allocation formulas. Options f - i will require testing under Code section 401(a)(4). Note: Unless option e is selected, skip question G13. Unless option f is selected, skip question G14. Unless option h is selected, skip question G15. Note: The other Non-Elective Contribution Allocation Formula specified must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. Note: In order to be covered by the IRS pre-approval letter, the other Non-Elective Contribution allocation formula must be a combination of Non-Elective Contribution allocation formulas available in this Plan Document. Any other formulas will not be covered by the IRS pre-approval letter. -23- G13. Integrated Non-Elective Contribution Allocation Formula a. If an integrated allocation formula is selected above the Plan will allocate the Non-Elective Contribution in a (select one): 1.2-step integrated allocation as described in Plan Section 2.3.5. The Base Contribution Percentage will be ____% The Excess Contribution Percentage will be ____% 2.4-step integrated allocation as described in Plan Section 2.3.5. The Base Contribution Percentage will be ____% Permitted Disparity will be limited to ____% 3.Pro-rata integrated allocation as described in Plan Section 2.3.5 A. Will the pro-rata integrated allocation formula satisfy the requirements under Code section 401(l) (select one)? 1.No. 2.Yes. B. If the Plan is Top-Heavy, the Non-Elective Contribution allocation formula will (select one): 1.remain the same with the Minimum Top-Heavy Allocation determined last. 2.change to the 4-step integrated allocation as described in Plan Section 2.3.5. b.If an integrated formula is selected above the Integration Level will be (select one): 1.The Taxable Wage Base (TWB) under the Social Security Act. 2. ____% of the TWB (if more than 100% testing under Code section 401(l) will be required) 3. The greater of $____ or ____% of the TWB (if more than 100% testing under Code section 401(l) will be required) 4. The lesser of $____ or the TWB (the dollar amount must be greater than 80% of the TWB or testing under Code section 401(l) will be required) 5. 80% of the TWB plus $____ (not more than $1,000 or testing under Code section 401(l) will be required) 6. Other (e.g., 80% of the TWB rounded up to the next $3,000):____. G14. Uniform Points Non-Elective Contribution Allocation Formula If a uniform points allocation formula is selected above the Plan will allocate the Non-Elective Contribution as specified below. a.The Non-Elective Contribution will be allocated (select one): 1.pro-rata by based on all points awarded for the Plan Year. 2. $____ for each point awarded to the Participant. 3. ____% of the Participant’s Compensation for each point awarded to that Participant. b.Points will be awarded to each Participant following the formula below (select all that apply): 1. ____ points for each year of age 2. ____ points for each Year of Credited Service 3. ____ points for each $____ (not more than $200) of Compensation 4. ____ points for ____ (e.g., 1 point for each Year of Credited Service at NRA) c. Total points for each Participant will be limited to ___ points. -24- G15. Group Allocation Non-Elective Contribution Allocation Formula If the group allocation formula is selected above the Plan will allocate the Non-Elective Contribution as specified below. a.For Group A: _____ the Non-Elective Contributions will be allocated (select one): 1.pro-rata based on Compensation to all Participants in the group. 2.the same dollar amount to all Participants in the group. 3.____ cents per Hour of Credited Service . Note: The allocation groups must be objectively determinable and must not violate the definite predetermined allocation formula requirement of Treasury Regulation section 1.401-1(b)(1)(ii).Note: The allocation groups cannot be designed in a manner to benefit only those non-HCEs with the lowest Compensation, shortest period of service, or who are needed to pass testing under Code section 410(b). Note: For Self-Employed Individuals, the allocation method must not result in a cash or deferred election under Treasury Regulation section 1.401(k)-1(a)(6). Note: The Employer must provide the Plan Administrator or Trustee, if applicable, written notification of the Non-Elective Contribution to be allocated to each allocation group. The instructions must be provided no later than the Employer's tax return due date, including extensions, of the year for which the allocation is made. G16. Limitations Non-Elective Contributions will be limited by (select one): a.No Plan imposed limitations b.The following limitations apply (select all that apply): 1. Minimum Non-Elective Contribution for each Participant for a Plan Year is (select one): A. $_____. B. ____ % of the Participant's Compensation. 2. Maximum Non-Elective Contribution for each Participant for a Plan Year is (select one): A. $________. B. ____ % of the Participant's Compensation. 3. other (e.g., maximum of $1,500 per HCE): ________ Note: The other limitations on Non-Elective Contributions must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. G17. Allocation Dates a.Non-Elective Contributions will be allocated as of the (select one): 1.last day of the Plan Year 2.last day of each pay period 3.last day of each Plan quarter 4.last day of each calendar month 5. other (e.g., last day of each calendar quarter): _____ b. If Non-Elective Contributions are not allocated on the last day of the Plan Year, any allocation conditions will be pro-rated. G18. 410(b) Coverage Failure Participants who normally would not be given an allocation of Non-Elective Contributions may be given an allocation in order to satisfy the requirements of Code section 410(b) (select one): a. No. The Plan must be amended in the case of a failure under Code section 410(b). b. Yes. The Code section 410(b) fail safe will be used in the case of a failure under Code section 410(b). -25- G19. Non-Elective Contributions to Disabled Participants a. Non-Elective Contributions will be allocated to the following Participants eligible to receive a Non-Elective Contribution without regard to any allocation conditions (select one): 1.not applicable. 2.all Disabled Participants who are not HCEs. 3.all Disabled Participants. b. Disabled Participants eligible to receive a Non-Elective Contribution under this section will (select one): 1. receive the contribution only for the Plan Year in which they became Disabled. 2. receive the contribution for ____ Plan Years provided they remain Disabled. However Non- Elective Contributions will cease (select one): A. at the end of the Plan Year in which the Participant attains ERA. B. at the end of the Plan Year immediately preceding the Plan Year in which the Participant attains ERA. C. at the end of the Plan Year in which the Participant attains NRA. D. at the end of the Plan Year immediately preceding the Plan Year in which the Participant attains NRA. Measuring Credited Service G20. Year of Credited Service The Method of Measuring a Year of Credited Service is (select one): a.Not Applicable. b. Hours of service method. A Year of Credited Service is ____ hours (not more than 1,000) in the Credited Service Computation Period. c.Elapsed time method. If option b is not selected, skip questions G20 and G22. G21. Credited Service Computation Period If the hours of service method is selected above, the Credited Service Computation Period will be (select one): a.the Plan Year. b.the 12-month period ending on the employment anniversary date. c.the calendar year ending with or within the Plan Year. d.the Employee’s Eligibility Computation Period. G22. Equivalencies a. Hours of Service If the hours of service method is selected above, when records of hours are not maintained the following equivalency will apply (select one). 1.Not applicable, actual hours will be used for all Employees. 2.Days worked (10 hours). 3.Weeks worked (45 hours). 4.Semi-Monthly or Bi-weekly Payroll period worked (95 hours). 5.Months worked (190 hours). b. Elapsed Time If the elapsed time method is selected above, credited service will be measured using (select one). 1.Exact date in years. 2.Exact date in months. 3. Calendar months with Employee granted a month of service if they work at least one Hour of Service in that month. 4.Nearest calendar month. 5.Completed calendar months. -26- G23. Break in Credited Service If the hours of service method is selected above, a Break in Credited Service occurs if an Employee fails to complete ______ (not more than 500) Hours of Service in a Credited Service Computation Period. Note: If actual hours are being used and no Hours of Service are completed then a Break in Service will be defined as the lesser of 500 hours or the number of Hours of Service needed to earn a Year of Credited Service. G24. Qualified Military Service In the case of death or Disability resulting from Qualified Military Service, the Participant will be eligible for an allocation as if they returned to employment with the Employer immediately prior to death or Disability (select one): a.No. b.Yes. H. Other Contributions Prevailing Wage Contributions H1. Designation of Contribution Prevailing Wage Contributions will be treated as the following contribution source (select one): a.Non-Elective Contributions. b.Qualified Non-Elective Contributions. c. The determination between Non-Elective Contribution and Qualified Non-Elective Contribution will be made at the time the contribution is allocated to the Participant’s Account. H2. Offset Prevailing Wage Contributions will offset the following Employer Contributions (select one): a. Not applicable; Prevailing Wage Contributions will supplement other Employer Contributions. b.the following Employer Contributions (select all that apply): 1.Non-Elective Contributions. 2.Safe Harbor Contributions. 3.Matching Contributions. 4.Other (e.g., Qualified Non-Elective Contributions): ____ H3. Prevailing Wage Allocation Formula Prevailing Wage Contributions will be allocated to Participants’ Account (select all that apply): a. ___% of Participant’s Compensation per payroll period. b. $___ per payroll period. c. pursuant to the following collective bargaining agreement: __________. d. ___% of Participant’s fringe benefits per payroll period. e.as described in the Prevailing Wage Addendum. f.Other (e.g., $.25 per Hour of Service): ___ Qualified Non-Elective Contributions (QNECs) H4. QNECs The Employer may always make QNECs on behalf of Participants in order to correct any testing or operational failures. In addition, the Employer may make additional discretionary QNECs (select one). a.No. b.Yes. Note: If option a is selected, skip questions H5 – H7. -27- H5. Eligibility for QNECs The following Participants will be eligible for the additional discretionary QNEC (select one): a.all Participants. b.the following Participants (select all that apply): 1.non-HCE Participants. 2.Participants employed on the last day of the Plan Year. 3  other (e.g., Participants covered under a collective bargaining agreement): ________. H6. QNEC Allocation Formula The additional discretionary QNEC will be allocated to Participants eligible for such contributions (select one): a.in proportion to a Participant's Compensation. b.as a uniform dollar amount. c. other (e.g., 3% of Compensation): _____ H7. QNEC Limitations The additional discretionary QNEC will be allocated to Participants eligible for such contributions (select one): a. ___ % (no more than 25%) of eligible Plan Compensation. b. $___ per Plan Year, but no more than 25% of eligible Plan Compensation. c. other (e.g., $1,000 per Plan Quarter, but not more than 25% of eligible Plan Compensation): _____ Qualified Matching Contributions (QMACs) H8. QMACs The Employer may always make QMACs on behalf of Participants in order to correct any testing or operational failures. In addition, the Employer may make additional discretionary QMACs (select one). a.No. b.Yes. Note: If option a is selected, skip questions H9 – H11. H9. Eligibility for QMACs The following Participants will be eligible for the additional discretionary QMAC (select one): a.all Participants. b.the following Participants (select all that apply): 1.non-HCE Participants. 2.Participants employed on the last day of the Plan Year. 3. other (e.g., Participants covered under a collective bargaining agreement): _____ H10. QMAC Allocation Formula The additional discretionary QMAC will be allocated to Participants eligible for such contributions (select one): a.in proportion to a Participant's Compensation. b.as a uniform dollar amount. c. Other (e.g., 3% of Compensation): _____. H11. QMAC Limitations The additional discretionary QMAC will be allocated to Participants eligible for such contributions (select one): a. ____ % (no more than 25%) of eligible Plan Compensation. b. $____ per Plan Year, but no more than 25% of eligible Plan Compensation. c. other (e.g., $1,000 per Plan Quarter, but not more than 25% of eligible Plan Compensation): ____ -28- Rollovers H12. Rollover Contributions Rollover Contributions may be contributed to the Plan (select one): a.No. b.Yes (select all that apply): 1.Direct Rollover Contributions are allowed. 2.In-Direct Rollover Contributions are allowed. Note: If option a is selected, skip questions H13 – H14. H13. Rollover Contribution Eligibility The following individuals will be permitted to make Rollover Contributions to the Plan (select one): a.all Employees. b.all Employees who do not fall into an excluded class. c. all Participants who are Employees, have met eligibility requirements, and passed an entry date. d.other (e.g., all Participants): _____ H14. Rollover Contribution Types In addition to pre-tax assets, Rollover Contributions of the following types will be permitted (select all that apply): a.Roth. b.non-Roth after-tax (direct rollover only). c.Participant loans (direct rollover only). d. Rollover of in-kind assets will be permitted for (select all that apply): 1.Participant loans. 2.other plans of the Employer. 3.all Rollover Contributions. I. Top-Heavy and Other Testing Minimum Top-Heavy Allocation I1. Top-Heavy Minimum Allocation In the event the Plan is Top-Heavy, if necessary, the Employer will (select one): a. make an additional contribution to meet the Top-Heavy Minimum Allocation requirements. b. first satisfy the Top-Heavy Contribution requirements then allocate the remaining Employer Contribution. I2. Top-Heavy Minimum Eligibility The Top-Heavy Minimum allocation will not be given to (select one): a.not applicable. b.the following Participants (select all that apply): 1.Participants who are Key Employees. 2. Participants who are Key Employees will be eligible at the discretion of the Plan Administrator. 3.Participants who are covered by a collectively bargained agreement. I3. Top-Heavy Minimum Allocation Formula The Top-Heavy Minimum Allocation will be (select one): a.The lesser of 3% or the highest percentage allocated to any Key Employee. b. ___% (at least 3%). -29- Multiple Plans Top-Heavy Provisions I4. Top-Heavy Minimum Allocation The Employer that maintains a qualified defined benefit plan in which any Participant in the Plan is, was, or could become a Participant adds the following optional provisions that it deems necessary to satisfy Code section 416 because of the required aggregation of multiple plans (select one): a. Not applicable - No other plan or all other plans terminated prior to the Effective Date of this Adoption Agreement. b. A minimum contribution allocation of 5% of each eligible Non-Key Employee's total Compensation shall be provided in a defined contribution plan of the Employer. c. A minimum benefit of the lesser of 2% times Years of Service or 20% of each eligible Non-Key Employee's Average Compensation shall be provided in a defined benefit plan of the Employer. d. A minimum benefit of the lesser of 2% times Years of Service or 20% of each eligible Non-Key Employee's Average Compensation shall be provided in a defined benefit plan of the Employer but offset by the amount contributed on such eligible Non-Key Employee's behalf under any defined contribution plan of the Employer. e. other (e.g., 6% of each eligible Non-Key Employee's total Compensation shall be provided in a defined contribution plan of the Employer): _____ Note: If option a is selected skip question I5. I5. Top-Heavy Assumptions The interest rate and mortality table used to establish the present value of accrued benefits in order to calculate the Top-Heavy Ratio under Code section 416 will be (select one): a. same as the following defined benefit plan: _____. b.other assumptions. Interest Rate: ____% Mortality table: __________ I6. Top-Heavy Duplications If Employer maintains two or more defined contribution plans, the Employer has determined that a Minimum Top-Heavy Allocation will be provided as follows (select one): a. Not applicable - No other plan or other plan terminated prior to the Effective Date of this Adoption Agreement. b. A minimum contribution of ___ % of each Non-Key Participant's Compensation shall be provided by: 1.this Plan. 2. The following defined contribution plan: __________. 3. Employees who will receive the minimum contribution under such other plan: __________. Note: Satisfying the Minimum Top-Heavy Allocation in another plan for some but not all of the Participants may cause the Plan to fail to satisfy the uniformity requirement of Treasury Regulations section 1.401(a)(4)- 2(b)(2)(ii) for plans using a design-based safe harbor, even though all other requirements of the safe harbor are met. ADP Tests I7. ADP Test For purposes of the ADP test, the Plan will use (select one): a.current year testing. b.prior year testing. If applicable, for the first Plan Year the ADP for non-HCEs will be (select one): 1.not applicable. 2.3%. 3.the ADP for non-HCEs for the Current Year. -30- ACP Tests I8. ACP Test For purposes of the ACP test, the Plan will use (select one): a.current year testing. b.prior year testing. If applicable, for the first Plan Year the ADP for non-HCEs will be (select one): 1.not applicable. 2.3%. 3.the ACP for non-HCEs for the Current Year. J. Vesting and Forfeitures All Elective Deferrals, Voluntary After-Tax Contributions, Prevailing Wage Contributions, Traditional Safe Harbor ADP Contributions, QNECs, QMACs, and SIMPLE 401(k) Contributions will be 100% vested and nonforfeitable at all times. Vesting Schedules J1. Matching Contribution Vesting Schedule A Participant’s Matching Contributions will vest according to the following schedule (select one): a.100% immediate vesting. b.6-year tiered vesting schedule. c.100% vested after ___ (no more than 3) Years of Vesting Service. d.another vesting schedule. 1. 0 % at less than 1 Year of Vesting Service. 2. 20 % at more than 1 but less than 2 Years of Vesting Service. 3. 40 % at more than 2 but less than 3 Years of Vesting Service. 4. 60 % at more than 3 but less than 4 Years of Vesting Service. 5. 80 % at more than 4 but less than 5 Years of Vesting Service. 6. 100 % at more than 5 but less than 6 Years of Vesting Service. 7.100% at more than 6 Years of Vesting Service. Note: Option a must be selected if the service requirement for Matching Contributions specified in C4 is greater than 1 Year of Eligibility Service or 12 months of Eligibility Service. Note: If option d is chosen and d4 is not 100%, d3 cannot be less than 20%, d4 cannot be less than 40%, d5 cannot be less than 60%, and d6 cannot be less than 80%. J2. Non-Elective Contribution Vesting Schedule A Participant’s Non-Elective Contributions will vest according to the following schedule (select one): a.100% immediate vesting. b.6-year tiered vesting schedule. c.100% vested after ___ (no more than 3) Years of Vesting Service. d.another vesting schedule. 1. 0 % at less than 1 Year of Vesting Service. 2. 20 % at more than 1 but less than 2 Years of Vesting Service. 3. 40 % at more than 2 but less than 3 Years of Vesting Service. 4. 60 % at more than 3 but less than 4 Years of Vesting Service. 5. 80 % at more than 4 but less than 5 Years of Vesting Service. 6. 100 % at more than 5 but less than 6 Years of Vesting Service. 7.100% at more than 6 Years of Vesting Service. Note: Option a must be selected if the service requirement for Non-Elective Contributions specified in C4 is greater than 1 Year of Eligibility Service or 12 months of Eligibility Service. Note: If option d is chosen and d4 is not 100%, d3 cannot be less than 20%, d4 cannot be less than 40%, d5 cannot be less than 60%, and d6 cannot be less than 80%. -31- J3. Top-Heavy Contribution Vesting Schedule Participant’s Top-Heavy Contributions will vest according to the following schedule (select one): a.not applicable. b.100% immediate vesting. c.6-year tiered vesting schedule. d.100% vested after ___ (no more than 3) Years of Vesting Service. e.another vesting schedule. 1. 0 % at less than 1 Year of Vesting Service. 2. 20 % at more than 1 but less than 2 Years of Vesting Service. 3. 40 % at more than 2 but less than 3 Years of Vesting Service. 4. 60 % at more than 3 but less than 4 Years of Vesting Service. 5. 80 % at more than 4 but less than 5 Years of Vesting Service. 6. 100 % at more than 5 but less than 6 Years of Vesting Service. 7.100% at more than 6 Years of Vesting Service. Note: If option e is chosen and e4 is not 100%, e3 cannot be less than 20%, e4 cannot be less than 40%, e5 cannot be less than 60%, and e6 cannot be less than 80%. J4. ACP Safe Harbor Contribution Vesting Schedule A Participant’s ACP Safe Harbor Contributions will vest according to the following schedule (select one): a.100% immediate vesting. b.6-year tiered vesting schedule. c.100% vested after ___ (no more than 3) Years of Vesting Service. d.another vesting schedule. 1. _______ % at less than 1 Year of Vesting Service. 2. _______ % at more than 1 but less than 2 Years of Vesting Service. 3. _______ % at more than 2 but less than 3 Years of Vesting Service. 4. _______ % at more than 3 but less than 4 Years of Vesting Service. 5. _______ % at more than 4 but less than 5 Years of Vesting Service. 6. _______ % at more than 5 but less than 6 Years of Vesting Service. 7.100% at more than 6 Years of Vesting Service. Note: If option d is chosen and d4 is not 100%, d3 cannot be less than 20%, d4 cannot be less than 40%, d5 cannot be less than 60%, and d6 cannot be less than 80%. J5. QACA ADP Safe Harbor Contribution Vesting Schedule A Participant’s QACA ADP Safe Harbor Contributions will vest according to the following schedule (select all that apply): a.not applicable. b.100% immediate vesting. c.100% vested after ___ (no more than 2) Years of Vesting Service. d.another vesting schedule. 1. ___ % at less than 1 Year of Vesting Service. 2. ___ % at more than 1 but less than 2 Years of Vesting Service. 3.100% at more than 2 Years of Vesting Service. J6. Accelerated Vesting A Participant will become 100% vested in all their accounts if they are still employed when they (select all that apply): a.reach ERA. b.die. c.become Disabled. d. other (e.g., terminated from service due to closing of factory): ________________________________________. -32- Measuring Vesting Service J7. Year of Vesting Service The Method of Measuring a Year of Vesting Service is (select one): a.Not Applicable. b. Hours of service method. A Year of Vesting Service is 1000 hours (not more than 1,000) in the Vesting Service Computation Period. c.Elapsed time method. J8. Vesting Service Computation Period If the hours of service method is selected above, the Vesting Service Computation Period will be (select one): a.the Plan Year. b.the 12-month period ending on the employment anniversary date. c.the calendar year ending with or within the Plan Year. d.the Employee's Eligibility Computation Period. J9. Equivalencies a. Hours of Service If the hours of service method is selected above, when records of hours are not maintained the following equivalency will apply (select one). 1.Not applicable, actual hours will be used for all Employees. 2.Days worked (10 hours). 3.Weeks worked (45 hours). 4.Semi-Monthly or Bi-weekly Payroll period worked (95 hours). 5.Months worked (190 hours). b. Elapsed Time If the elapsed time method is selected above, credited service will be measured using (select one). 1.Exact date in years. 2.Exact date in months. 3. Calendar months with Employee granted a month of service if they work at least one Hour of Service in that month. 4.Nearest calendar month. 5.Completed calendar months. J10. Break in Vesting Service If the hours of service method is selected above, a Break in Vesting Service occurs if an Employee fails to complete 500 (not more than 500) Hours of Service in a Vesting Service Computation Period. Note: If actual hours are being used and a no Hours of Service are completed then a Break in Service will be defined as the lesser of 500 hours or the number of Hours of Service needed to earn a Year of Vesting Service. J11. Exclusions from Years of Vesting Service The following Years of Vesting Service will be excluded when determining a Participant’s Vesting Account Balance (select one): a.all Years of Vesting Service are counted. b.the following years will be excluded (select all that apply): 1.years before the Participant attains age 18. 2.years before the Plan's Original Effective Date. 3. years before a predecessor plan’s original effective date. The predecessor plan’s original effective date is __/__/____. J12. Vesting for Disabled Participants A Disabled Participant will continue to earn Vesting Service as though they were still employed (select one): a.No. b.Yes. -33- J13. Reemployment If a Participant has been rehired their Years of Vesting Service will be calculated using the following rules (select one): a.not applicable. b.5 one-year break in service rule. c.one-year hold out rule. d. all Years of Vesting Service are included for pre-break in vesting service Account balances. Forfeitures J14. Use of Forfeitures Forfeitures may be used to (select one): a. offset Employer Contributions at the Plan Administrator’s discretion in a nondiscriminatory and uniform manner. b. provide a supplemental Employer Contributions at the Plan Administrator’s discretion in a nondiscriminatory and uniform manner. Note: Forfeitures may always be used to reduce administrative expense of the Plan or to restore forfeited account balances of rehired Employees. Note: If option a is selected skip question J15 and J16. J15. Forfeiture Eligibility Requirements Matching Contributions Non-Elective Contributions a.Participants eligible to receive an allocation of the respective type of contribution   b.All Participants   c.Participant who are employed on the date the Forfeitures are determined   d.Participant who are employed on the date the Forfeitures are allocated   e.Other:  Specify the other eligibility requirements (e.g., Participants who are employed on the last day of the Plan Year). 1.Matching Contributions: _____ 2.Non-Elective Contributions: _____ J16. Forfeiture Allocation Method If Forfeitures will be used to supplement Employer Contributions (select one): Matching Contributions Non-Elective Contributions a.In the same manner as the respective Employer Contribution for the Plan Year   b.pro-rata for the Plan Year   c.pro-rata for the Compensation Computation Period   d.Other:  Specify the other allocation method (e.g., following the Non-Elective Allocation Formula). 1.Matching Contributions: _____ 2.Non-Elective Contributions: _____ J17. Forfeiture Determination Period Forfeitures will be determined (select one): a.during the Plan Year. b.since the prior Valuation Date. c.since the prior allocation date. d.other (e.g., for the period before the prior Valuation Date): ______ Note: The “Other” forfeiture determination period must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. -34- J18. Forfeiture Allocation Date Forfeitures will be allocated on (select all that apply): a.each allocation date for Non-Elective Contributions b.each allocation date for Matching Contributions c.each Valuation Date d.other (e.g., each Anniversary Date): ______ Note: The “Other” forfeiture allocation date must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. J19. Deemed Forfeiture Date The non-vested portion of Participant’s Account Balance will be deemed distributed and forfeited as of (select one): a.the Participant's date of termination. b.the last day of the Plan Year that contains the Participant’s date of termination. c.the last day of the Plan Year that contains the Participant’s fifth consecutive break in service. d.other (e.g., the Valuation Date next following the Participant’s date of termination): ______ Note: The “Other” deemed forfeiture date must be objectively determinable, may not be specified in a manner that is subject to Plan Administrator discretion, and may not discriminate in favor of HCEs. The Plan Administrator will make all determinations in connection with such issues in a uniform, nondiscriminatory manner. K. Distributions REA Requirements K1. REA Safe Harbor The Plan meets the requirements to be exempt from the QJSA and spousal consent rules of REA (select one). a.No. b.Yes, REA will apply only to assets merged in from plans subject to the REA requirements. c.Yes. K2. Qualified Joint and Survivor Annuity (QJSA) If the Plan does not meet the requirement to be a REA safe harbor plan, the Qualified Joint and Survivor Annuity percentage is (select one). a.not applicable. b. ___% (no less than 50 and no more than 100). Note: In addition to the percentage provided for the Qualified Joint and Survivor Annuity, a Participant must be permitted to elect an optional form of annuity. If the selected Qualified Joint and Survivor Annuity percentage is less than 75%, the Qualified Optional Survivor Annuity will be 75%. If the selected percentage is 75% or more, the Qualified Optional Survivor Annuity will be 50%. Forms of Distribution K3. Available Forms of Distributions Participants eligible to take a distribution can take the distribution in the following format(s)(select all that apply): a. lump sum distributions with the following limitations (e.g., not to exceed $10,000): ________________________________________ b. partial, non-periodic distributions with the following limitations (e.g., each distribution must be at least $200): ________________________________________ c. installment payments with the following limitations (e.g., each distribution must be at least $200): ________________________________________ d. Annuities with the following limitations (e.g., each distribution must be at least $200): _____. Note: If a distribution form is selected and no limitation is completed, no further limitation will apply. -35- K4. Minimum Distribution Amount a. The Plan will provide the lesser of the account balance or $ _____ (amount cannot exceed $100) to a Participant with no vested balance. K5. Distribution due to Disability A distributable event due to Disability occurs (select all that apply): a. Termination Date. (Distributable event occurs upon the Participant's termination of employment.) b. The Participant's actual date of Disability, as determined by the Plan Administrator. c. ___ months after the Participant's actual date of Disability, as determined by the Plan Administrator. d. The date the Plan Administrator determines the Participant to be Disabled. K6. Distribution Determination Date For distribution purposes due to a distributable event, the value of a Participant's vested account balance shall be determined as of (select one for each applicable event): Termination for Reasons Other Than Death, Disability, or Retirement Death, Disability, or Retirement Elective Deferrals, Voluntary After-Tax, and Rollover Accounts a.The last day of the Plan Year coinciding with or next following the date of the distributable event.    b.The Valuation Date coinciding with or next following the date of the distributable event.   c.The Valuation Date coinciding with or immediately preceding the date of the distributable event.    d.As soon as administratively feasible following the date of the distributable event, based on the preceding Valuation Date.    e.The Valuation Date preceding the Participant's Normal or Early Retirement Date.    f.Other:   Specify the other determination date (e.g. last day of the Plan Year). 1.Termination for Other Reasons: _____. 2.Death, Disability, or Retirement: _____. 3.Elective Deferrals, etc.: _____. K7. Time of Distribution For distributions other than mandatory cash out distributions, the distribution shall be made as indicated below: a.Distributions at termination for reasons other than death, Disability, or retirement will be (select one): 1.made within a reasonable period following the Distribution Determination Date. 2.made within a reasonable period following the Anniversary Date. 3.Deferred until the Participant's Normal or Early Retirement Date. b.Distributions to Participants who have a distributable event due to death, Disability, or retirement will be (select one): 1.made within a reasonable period following the Distribution Determination Date. 2.made within a reasonable period following the Anniversary Date. c.Distributions of Elective Deferrals, Voluntary After-Tax, and Rollover Accounts will be (select one): 1.made within a reasonable period following the Distribution Determination Date. 2.made within a reasonable period following the Anniversary Date. -36- K8. Minimum Distribution for Rollovers In order to be considered an Eligible Rollover Distribution, the total distribution must be at least (select one): a.No limit b.$200. c. $ ____ (amount cannot exceed $200) In-Service Distributions K9. In-Service Distributions In-Service Distributions are available under the Plan (select one): a.No. b.Yes. Note: If option a is selected, skip questions K10 – K14. K10. In-Service Distribution Event In-Service Distributions will be permitted from the following Accounts upon reaching the specified event (select one): Age 59½ NRA ERA Disability Other Age Specify age a.All Sources      ____ b.the following sources (select all that apply):     1.Pre-Tax Elective Deferrals      ____ 2.Roth Elective Deferrals      ____ 3.ADP Safe Harbor Contributions     ____ 4.QNECs      ____ 5.QMACs      ____ 6.Safe Harbor Contributions      ____ 7.Matching Contributions      ____ 8.Non-Elective Contributions     ____ 9.Rollover Contributions      ____ 10.Transfer Contributions      ____ 11.Voluntary After-Tax Contributions      ____ 12.Other (e.g. Money Purchase Contributions)     ____ ________________________________________ Note: Regardless of what is selected above, In-Service Distributions from Elective Deferrals, ADP Safe Harbor Contributions, QNECs, and QMACs cannot take place before the Participant has reached age 59 ½ or incurred a disability under Code section 22(e). Note: Participants will be eligible for an In-Service Distribution upon meeting one or more of the requirements selected above. -37- K11. Other In-Service Distribution Events In-Service Distribution will be permitted from the following Accounts for the specified reason (select all that apply): Matching Non-Elective ACP Safe Harbor Contributions Contributions Contributions a.Amounts have been allocated for __ years.    (Must be at least 2.) b.Require participation for at least __ years.    (Must be at least 5.) c.Amounts have been allocated for __ years    (Must be at least 2.) AND require participation for at least __ years. (Must be at least 5.) d.Amounts have been allocated for __ years    (Must be at least 2.) OR require participation for at least __ years. (Must be at least 5.) Note: Participants will be eligible for an In-Service Distribution upon meeting one or more of the requirements selected above. These events are independent of the events selected in K10 above. K12. In-Service Distributions at Any-Time In-Service Distributions are permitted under the Plan at any-time for the following sources (select all that apply): a.Rollover Contributions. b.Voluntary After-Tax Contributions. K13. In-Service Distributions for In-Plan Roth Rollover Accounts In-Service Distributions of assets held in In-Plan Roth Rollover Accounts will be permitted (select one): a. when a distribution of the assets would have been permitted prior to the In-Plan Roth Rollover. b.at any time. c.other (e.g., age 59½): ____ Note: In-Plan Roth Rollovers must be limited to either distribution options permitted under the Plan or distribution options permitted under the Code and Treasury Regulations in order to allow for the distributions of In-Plan Roth Rollover Contributions at any time. K14. In-Service Distributions Limitations All In-Service Distributions will be limited by the following (select one): a.No limitations. b.The following limitations (select all that apply): 1.Participant must be 100% vested in all Plan Accounts. 2.Participant may request ___ In-Service Distributions during each Plan Year. 3. each In-Service Distribution must be at least the lesser of $ ___ (no greater than $1,000) or the total value of the vested account balances eligible for an In-Service Distribution. 4.other (e.g., five distributions in total): _____. Note: One request, regardless of the number of Accounts from which the distribution is to be taken, is considered a single In-Service Distribution. Hardship Distributions K15. Hardship Distributions Hardship Distributions will be permitted from the following Accounts for the following reasons (the safe harbor hardship reasons is defined under Plan Section 2.5.10) (select one): Safe Harbor Non-Safe Harbor Hardship Definition Hardship Definition a.None b.All Accounts Listed Below   c.The following Accounts (select all that apply):  1.Matching Contributions   2.Non-Elective Contributions   3.Rollover Contributions   -38- 4.Transfer Contributions   5.Voluntary After-Tax Contributions   6.Other (e.g., Top-Heavy Contributions):  ________. Note: If option a is selected, skip questions K16 – K17. K16. Non-Safe Harbor Hardship Distributions If Hardship Distributions are allowed for a non-safe harbor hardship definition, the definition will be (select one): a. A hardship will be defined as immediate and heavy financial need where the Participant lacks other available resources. The determination will be made by the Plan Administrator in a uniform and non- discriminatory manner. b.Other (e.g., medical expenses): _____. K17. Limitations on Hardship Distributions Hardship Distributions will be limited by the following (select one): a.no limitations. b.the following limitations (select all that apply): 1. a Participant can receive no more than ___ Hardship Distributions in each Plan Year. 2. each Hardship Distribution must be at least $ ___ or 100% of the Participant’s Account Balance available for Hardship Distributions, if less. 3. other (e.g., must take any available loan from the Plan): _____. Other Distribution Provisions K18. Distributions due to Qualified Military Service Participants performing Qualified Military Service will be permitted to take the following distributions (select one): a.None. b.Yes, the following distributions are permitted (select all that apply). 1.Deemed Severance Distributions. 2.Qualified Reservist Distributions. K19. Permissible Withdrawals If the Plan contains an EACA provision (select one): a.No. b. Yes, Permissible Withdrawals can be requested within ___ (no less than 30 and no more than 90) days of the first automatic contribution under the EACA. K20. Qualified Domestic Relations Orders Distributions to an Alternate Payee are permitted while the Participant continues to be employed on or after the date a Domestic Relations Order is determined to be a Qualified Domestic Relations Order by the Plan Administrator (select one): a.No. b.Yes. K21. Non-REA Safe Harbor Assets Distributions of Account Balances transferred from a Money Purchase Pension Plan, Target Benefit Plan or defined benefit plan can be distributed upon (select one): a.Not applicable. b.attainment of age 62. c. other (e.g., age 62 and 100% vested): ____ (cannot be earlier than age 62). -39- Required Minimum Distributions K22. Required Beginning Date The Required Beginning Date for Participants who are not a 5% Owner will be (select one): a. April 1st of the calendar year following the calendar year in which the Participant attains age 70½. b. the later of April 1st of the calendar year following the calendar year in which the Participant attains age 70 ½, or April 1st of the calendar year following the calendar year in which the Participant retires. c. the Participant has the ability to choose between (1) April 1st of the calendar year following the calendar year in which the Participant attains age 70 ½ or, (2) if later the April 1st of the calendar year following the calendar year in which the Participant retires. K23. Distributions to Beneficiaries Beneficiaries of deceased Participants (select one): a.may not elect to apply the 5-year rule. b.may elect to apply the 5-year rule. Mandatory Cash-Out and Automatic Direct Rollover K24. Mandatory Cash-Out Threshold The Mandatory Cash Out threshold is (select one): a.no Mandatory Cash Out. b.$ 5000. Note: If option a is selected, skip questions K25 – K27. K25. Mandatory Cash Out Timing The Mandatory Cash Out will occur _____ following the Participant’s termination from service (select all that apply). a.as soon as administratively feasible b.as soon as administratively feasible after the next Valuation Date c.as soon as administratively feasible after the last day of the Plan Year K26. Rollover Contributions Included in Mandatory Cash Out Rollover Contributions will be included when determining if the Mandatory Cash Out threshold has been exceeded (select one): a.No. b.Yes. K27. Automatic Rollover If a Mandatory Cash-Out distribution takes place (select one). a. All Mandatory Cash-Out Distributions will be paid directly to the Participant or Beneficiary. b. Mandatory Cash-Out Distributions not in excess of $ 1000 (cannot exceed $1,000) will be paid directly to the Participant or Beneficiary. Mandatory Cash-Out Distributions in excess of the specified amount will be directly rolled over into an IRA. c.All Mandatory Cash-Out Distributions will be directly rolled over into an IRA. Note: In order to select option a, the Mandatory Cash-Out Level must be $1,000 or less and Rollover Accounts must be included in determining the Mandatory Cash-Out Level. Note: For the purpose of the automatic rollover rules, the determination of the amount of the Mandatory Cash- Out Distribution amount is made separately for Roth and non-Roth Account balances. L. Administrative Provisions Loans L1. Loans Participants will be permitted to take loans from their Account balance (select one): a.No. b.Yes. -40- Earnings L2. Designation of Contribution If the Plan does not value Accounts on a daily basis, for Participants who receive distributions on any date other than a Valuation Date, earnings will be (select one): a.not applicable. b.credited solely as of the immediately preceding Valuation Date. c.the actual earnings on the date of distribution. L3. Earnings on Forfeiture Accounts Forfeiture Account holding the Plan's aggregate Forfeitures be subject to Trust earnings (select one): a.No. b.Yes. Investments L4. Participant Direction Participants may direct the investment of their following Accounts (select one): a.None b.All Accounts c.The following Accounts (select all that apply): 1.Pre-Tax Elective Deferrals 2.Roth Elective Deferrals 3.Safe Harbor Contributions 4.QNECs 5.QMACs 6.Matching Contributions 7.Non-Elective Contributions 8.Rollover Contributions 9.Transfer Contributions 10.Voluntary After-Tax Contributions 11.Other (e.g., Top-Heavy Contributions): _____. Note: If option a is selected skip questions L5 – L6. L5. Limitations on Participant Direction Participant direction of investments will be limited by the following (select one): a.no limitations. b.the following limitations (select all that apply): 1.must be 100% vested in directed Accounts. 2.other (e.g., XXXXX): _____ L6. 404(c) The Plan intends to comply with ERISA section 404(c) (select one): a.No. b.Yes. L7. Life Insurance Life Insurance Policies may be purchased to provide incidental insurance benefits (select one): a.No. b.Yes. -41- M. Authorizations and Signatures The name, address and telephone number of the Document Sponsor which is also the document provider, is: Document Sponsor and Document Provider Rudd & Company PLLC 725 S. Woodruff Ave. Idaho Falls, ID 83401 (208) 529-9276 This Plan must be registered with the Document Sponsor within 60 days of adoption of this document, and the Document Serial Number assigned by the Document Sponsor shall be affixed to this signature page. The adopting Employer must notify the Document Sponsor if the Plan is terminated, merged, or of any changes in the name, address, or EIN of the adopting employer at least annually, and within 30 days of any request of the Document Sponsor. If the adopting Employer terminates its relationship with the Document Sponsor, its Plan will no longer be considered a pre-approved plan sponsored by the Document Sponsor. Unregistered use of this document will result in the Plan no longer participating in this pre-approved plan, and the document will be considered an individually designed plan, without reliance on the opinion letter of the Document Sponsor, which could result in the disqualification of the Plan. If the Employer's Plan fails to attain or retain qualification, such Plan will no longer participate in this pre-approved plan and will be considered an individually designed plan. The Document Sponsor will inform the Employer of any amendments made to the Plan or of the discontinuance or abandonment of the Plan. The adopting Employer may rely on an opinion letter issued by the Internal Revenue Service as evidence that the Plan is qualified under Code section 401 except to the extent provided in Revenue Procedure 2011-49. The Employer may not rely on the opinion letter in certain other circumstances or with respect to certain qualification requirements that are specified in the opinion letter issued with respect to the Plan and in Revenue Procedure 2011- 49. In order to have reliance in such circumstances or with respect to such qualification requirements, application for a determination letter must be made to Employee Plans Determinations of the Internal Revenue Service. This Adoption Agreement may be used only in conjunction with Base Plan Document #20 (the Rudd & Company PLLC Pre-Approved Defined Contribution Plan) Revised 06/30/2020. * * * The Employer hereby adopts the Plan as evidenced by the foregoing Adoption Agreement on this 1st day of January, 2022. Employer: City of Rexburg ________________________________ Jerry L. Merrill Mayor Plan Serial Number: R26010-2022 -42-