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® Contributed to the HC Accounts of other Participants on a per capita basis. <br /> ❑ Other (Describe): <br /> 4.11 Which plan pays first: <br /> ❑ This Plan <br /> ® Flex plan sponsored by the Adopting Employer. <br /> 4.12(d) Other Limitations, if any: <br /> ARTICLE V: CONTRIBUTIONS AND TRUST <br /> 5.1 Employer Contribution amount, timing, restrictions (check all that appi)4: <br /> One Time Contribution: <br /> ® Fixed dollar amount As determined by each CBA <br /> Memorandum of Understanding, Labor Contract or any other agreement for a Union <br /> or Non-Represented Participant. <br /> ❑ Fixed formula (Describe): <br /> ® Restrictions, if any(Describe): Mid-Year participation is Pro-rated. <br /> Contributed on (Identify Date): <br /> Recurring Contributions: <br /> ® Fixed dollar amount <br /> ❑ Per month <br /> ❑ Per quarter <br /> ❑ Per year <br /> ❑ Other(Describe): As determined by each CBA, Memorandum of <br /> Understanding, Labor Contract or any other agreement for a Union or <br /> Non-Represented Participant. *Note: Second year applies to First year <br /> lump sum payment group. <br /> ❑ Restrictions, if any(Describe): <br /> ❑ Fixed formula (Describe): <br /> ❑ Per month <br /> ❑ Per quarter <br /> ❑ Per year <br /> ❑ Other(Describe): <br /> ❑ Restrictions, if any(Describe): <br /> ©Copyright 2017 Hitesman&Wold,P.A. Page 5 <br /> HRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA) <br />