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ADOPTION AGREEMENT <br /> CAFETERIA PLAN <br /> The undersigned adopting employer hereby adopts this Plan. The Plan is intended to qualify as a cafeteria plan under <br /> Code section 125. The Plan shall consist of this Adoption Agreement, its related Basic Plan Document and any related <br /> Appendix and Addendum to the Adoption Agreement. Unless otherwise indicated, all Section references are to Sections <br /> in the Basic Plan Document. <br /> COMPANY INFORMATION <br /> 1. Name of adopting employer(Plan Sponsor): City of Everett <br /> 2. Address: 2930 Wetmore Ave 5-A <br /> 3. City: Everett <br /> 4. State: WA <br /> 5. Zip: 98201 <br /> 6. Phone number: (425)257-8767 <br /> 7. Fax number: (425)257-8754 <br /> 8. Plan Sponsor EIN: 91-6001248 <br /> 9. Plan Sponsor fiscal year end: December 31 <br /> 10. Entity Type: <br /> a. Plan Sponsor entity type: <br /> i. 0 C Corporation <br /> ii. 0 S Corporation <br /> iii. 0 Non-Profit Organization <br /> iv. 0 Partnership <br /> v. 0 Limited Liability Company <br /> vi. 0 Limited Liability Partnership <br /> vii. 0 Sole Proprietorship <br /> viii. 0 Union <br /> ix. 0 Government Agency <br /> x. 0 Other: <br /> xi. If"Union"(10a.viii) is selected, enter name of the representative of the parties who established or <br /> maintain the Plan: <br /> 11. State of organization of Plan Sponsor: Washington <br /> 12. Controlled Groups/Affiliated Service Groups <br /> a. 0 The Plan Sponsor is a member of an affiliated service group. List all members of the group (other than the <br /> Plan Sponsor): <br /> 13. Controlled Groups <br /> a. 0 The Plan Sponsor is a member of a controlled group. List all members of the group (other than the Plan <br /> Sponsor): <br /> NOTE:Affiliated service group members and controlled group members may adopt the Plan with the approval of the <br /> 1 Copyright©2002-2018 <br /> Benefit Plans Administrative Services LLC <br />