Benefit Plans Administrative Services 12/26/2018

Plan Sponsor. NOTE:Listing affiliated service group members and controlled group members is for information purposes only and is optional. Participating Employers in the Plan are listed in Addendum. PLAN INFORMATION A. GENERAL INFORMATION AND DEFINITIONS 1. Plan Number: 501 2. Plan Name: a. City of Everett b. Section 125 Cafeteria Plan 3. Effective Date:January 01, 2000 a. PJ Is this a restatement of a previously-adopted plan? b. Effective date of Plan restatement:January 01, 2019 ("Restatement Date") 4. Plan Year: a. Plan Years mean each 12-consecutive month period ending on December 31 (e.g. December 31). If the Plan Year changes, any special provisions regarding a short Plan Year shall be placed in the Addendum to the Adoption Agreement. b. 0 The Plan has a short Plan Year. The short Plan Year begins and ends on Plan Features 5. The following Benefits are available under the Plan: a. Q Premium Conversion Account b. Q Health Flexible Spending Account c. 0 Limited Purpose HSA-Compatible Health Flexible Spending Account d. ❑ Post-Deductible HSA-Compatible Health Flexible Spending Account e. Q Dependent Care Assistance Plan Account f. 0 Adoption Assistance Flexible Spending Account g. 0 Health Savings Account h. 0 Flexible Benefits Credits i. 0 PTO Purchase/Sale 6. Simple Cafeteria Plan a. 0 The Plan is intended to qualify as a simple cafeteria plan under Code section 125(j). b. The Employer shall make contributions to the Plan as follows: i. 0 % (no less than 2%) of an Eligible Employee's Compensation for the Plan Year. ii. 0 % (at least 200%) of an Eligible Employee's salary reduction contribution for the Plan Year, but no less than 6%of the Eligible Employee's Compensation for the Plan Year. 2 Copyright©2002-2018 Benefit Plans Administrative Services LLC