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RESOLUTION NO. 02-88
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF TUSTIN, CALIFORNIA,
AMENDING ITS FLEXIBLE BENEFITS PLAN
WHEREAS, the City adopted a Cafeteria Flexible Benefits Plan (Plan)in
1994 within the context of Section 125 of the Internal Revenue Code for the benefit of
eligible City employees; and
WHEREAS, such Plan as been amended when appropriate; and
WHEREAS, the City Council wishes to amend the Cafeteria Flexible Benefits
Plan within the context of Section 125 of the Internal Revenue Code for the benefit of
eligible City employees.
NOW, THEREFORE, the City Council of the City of Tustin, California does
hereby amend its Flexible Benefits Plan (consisting of the flexible benefits plan
document, the Adoption Agreement, and component benefit plans and policies) by
increasing the allowable Medical Care Expense Reimbursement from $3,000 per
calendar year to $5,000 per calendar year for the City of Tustin effective January 1,
2003.
Resolved further, that the City Manager or his designee may, without a
further Resolution, execute the Adoption Agreement and any related documents or
amendments which may be necessary or appropriate to adopt the plan or maintain its
compliance with applicable federal, state and local law.
Passed and adopted by the City Council of the City of Tustin at a regular
th
meeting held on the 16 day of September, 2002.
J~~ ~HOMAS, MAYOR
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S:\City Council Agenda Items\CAFETERIAPLANRESO2002.DOC
ADOPTION AG REEMENT FOR: CITY OF TUSTIN
FLEXIBLE BENEFITS PLAN
ESTABLISHMENT OF THE PLAN
The Employer named below established as set forth herein, a Flexible Benefits Plan (the "Plan") as of the Effective Date
consisting of this Adoption Agreement, the Plan Document and the Benefit Plans and Policies specifically referred to herein
including the Dependent Care Expense Reimbursement Plan and/or a Medical Care Expense Reimbursement Plan. The
purpose of the Flexible Benefits Plan is to provide eligible employees a choice between cash and the specified welfare benefits
described in this Adoption Agreement. Pre-tax premium elections under the Plan are intended to qualify for the exclusion from
income provided in Section 125 of the Internal Revenue Code of 1986.
EMPLOYER INFORMATION
1) Name and Address of Employer/
CITY OF TUSTIN
Plan Administrator:
2) Employer's Telephone Number:
3) Employer's Federal Tax ID Number:
4) 125 Start Date:
5) Effective Date of the Plan:
6) Last Day of the Plan Year:
Subsequent Plan Years:
7) Name and Address of the Plan
Service Provider:
8) Name and Title of Registered Agent
for Service of Legal Process:
9) Affiliated Employers which will Participate in the
ARLENE MARKS
300 CENTENNIAL WAY
TUSTIN, CA 92780
(714) 573-3052
95-6O0O804
01/01102
01/01/02
12131102
01101-12/31
CLAIMS PROCESSOR: FLEX ONE
1932 WYNNTON ROAD
COLUMBUS, GA 31999
WILLIAM A HUSTON
CITY MANAG ER
Plan:
Amendpgs
( )
( )
(x)
( )
10) Employer's Type of Business: OTHER
ELIGIBILITY
All Employees employed by the Employer shall be eligible to participate under the Plan except the following: (Describe)
TEMPORARY OR SEASONAL OR NON-REGULAR PART-TIME
An eligible Employee may become a Participant in the Plan:
Immediately, upon the first day of employment (but not prior to the Effective Date of the Plan).
On the day following commencement of employment.
On the first day of the month following 30 days of employment.
OTHER
provided the Employee completes a Salary Redirection Agreement. However, eligibility for coverage Under any given
Benefit Plan or Policy shall be determined by the terms of that Benefit Plan or Policy, and reductions of the Employee's
Compensation to 'pay Pre-tax or After-tax Premiums shall commence when the Employee becomes covered under the
applicable Benefit Plan or Policy.
An eligible Employee may become a Participant in .the Dependent Care and/or Medical Expense Reimbursement Plan(s) (if
elected below):
( ) On the same day such Employee is eligible for the Pre-Tax Premium benefits under the Plan.
( ) On the day following commencement of employment.
( ) On the first day of the month following days of employment.
( ) OTHER
provided the Employee completes a Salary Redirection Agreement selecting such benefits.
BENEFITS PROVIDED UNDER THE PLAN
The Employer elects to offer to eligible employees the following Benefit Plans and Policies subject to the terms and conditions of
the Plan. These component Benefit Plans and Policies are specifically incorporated herein by reference. The maximum Pre-tax ·
Premiums a Participant can contribute via the Salary Redirection Agreement is the aggregate cost of the applicable Benefit Plans
or Policies selected minus any Non-elective Contribution made by the Employer. It is intended that such Pre-tax Premium
accounts shall, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for State
insurance law purposes. Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
appendix to this Plan.
( X ) Group Medical Coverage
(x)
( )
(x)
(x)
(x)
( )
(x)
(x)
(x)
(x)
(x)
(x)
(x)
( )
Vision Care Coverage
Disability Income-Short Term (A&S)
Cancer Insurance
Group Dental Coverage
Group Term Life Insurance
Disability Income-Long Term (LTD)
Intensive Care Insurance
Accident Insurance
Hospital Indemnity Insurance (HIP)
Specified Health Event
Personal Sickness Indemnity (PSI)
Medical Care Expense Reimbursement described in Section 5.01(b) of the Plan, not to exceed $ 5,000 per Plan Year
pursuant to the CITY OF TUSTIN
Medical Care Expense Reimbursement Plan.
Dependent Care Expense Reimbursement described in Section 5.01(c) of the Plan not to exceed $5,000 per Plan Year or
$2,500 for married filing separate returns pursuant to the CITY OF TUSTIN
Dependent Care Expense Reimbursement Plan.
Opt-out Option: Additional taxable compensation for certain participants who opt-out of certain coverages (as described
in enrollment materials).
THE FUNDING AGENT
The Employer selects the following Funding Agent for the Plan (check one):
The Employer, which will comply with the requirements of Section 7.02 of the Plan.
The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive contributions under
the Plan in accordance with Section 7.03 of the Plan.
ADMINISTRATIVE EXPENSES
Administrative Expenses incurred in operating the Plan shall be paid by (check one):
The Employer, except as otherwise noted in the Plan.
The Participants, except as otherwise noted in the Plan.
EMPLOYER'S ACKNOWLEDGMENT
As evidenced by the formal execution of this Adoption Agreement, the undersigned Employer adopted and established this Plan on
the Effective Date as the Flexible Benefits Plan of the undersigned Employer. In doing so, the undersigned Employer
acknowledges that this Adoption Agreement and this Plan are important legal instruments with significant legal and tax implications.
The .Employer also acknowledges that it has read this Adoption Agreement and the Plan in their entirety, has consulted
independent legal and tax counsel other than representatives of American Family Life Assurance Company of Columbus (AFLAC~),
to the extent considered necessary, and accepts full responsibility for participation of employees hereunder and the operation of the
· Plan. The Employer acknowledges that as Plan Sponsor and the Plan Administrator, it shall have sole responsibility to comply with
all filing, reporting and disclosure requirements imposed by the Department of Labor, Internal Revenue Service, or any other
government agency, specifically including, but not limited to, creating and filing Form 5500s and preparing and distributing
Summary Plan Descriptions. Furthermore, the Employer further acknowledges that it shall bear sole responsibility for amending
the Plan as necessary to ensure compliance with applicable tax, labor, and other laws and regulations. Employer acknowledges
receipt of the checklist of Plan Sponsor Responsibilities included in the Plan Document Request form and has agreed to the
obligations set forth therein.
It is also understood and agreed that Amedcan Family Life Assurance Company of Columbus (AFLAC) and its Subsidiaries, agents,
and representatives, are not providing legal or tax advice to the undersigned Employer in connection with this Plan and that no
representations, are made by it with respect to the operation of the Flexible Benefits Plan pursuant to the sample documents
provided by American Family Life Assurance Company of Columbus (AFLAC) to the Employer.
This Plan shall be construed and enforced according to the Internal Revenue Code of 1986, as amended from time to time, the
applicable regulations thereto and the laws of the State of the principal place of business of the Employer.
IN WITNESS WHEREOF, the Employer has caused this Plan and Adoption Agreement to be executed .on the day of
to ratify the adoption of the Plan adopted and effective as of the Effective Date.
WITNESS:
Employer:
By:
Title:
Date:
Corporate Officer
3 Amendpgs
RESOLUTION ADOPTING A FLEXIBLE BENEFITS PLAN
The undersigned hereby certifies that the following described Resolution was officially and legally adopted at the duly authorized
official meeting of the body with legal authority (hereafter "Authority") to pass said Resolution. Said meeting was held on the date set
forth below.
WHEREAS, the Authority wishes to adopt a cafeteria plan within the context of Section 125 of the Internal Revenue Code for the
benefit of the employer's eligible employees.
NOW, THEREFORE, BE IT RESOLVED, that the Authority hereby adopts the Flexible Benefits Plan (consisting of the flexible
benefits plan document, the Adoption Agreement, and component benefit plans and Policies) for the Employer named herein below
effective as of the date specified in the Adoption Agreement.
RESOLVED FURTHER, that any officer of the employer may, without a further resolution, execute the Adoption Agreement and any
related documents or amendments which may be necessary or appropriate to adopt the plan or maintain its compliance with
applicable Federal, State and local law.
Name:
Body With Legal Authority of Employer To Pass Resolution:
(Examples - Board of Directors, Board of Commissioner, etc.)
Date of Official Meeting of Authority
at which Resolution was Legally Passed:
Signature of Person with Authority to Certify that
Resolution was Legally Passed
Corp.orate Officer
Print Name and Title of Person above
[ OFFICIAL SEAL ] Date:
*Note: Legal requirements for a valid Board of Directors Resolution vary from State to State. This document is merely a suggested
form. Each Employer should consult with its own legal counsel to ensure compliance with applicable law.
4 Amendpgs
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION FOR:
CITY OF TUSTIN
FLEXIBLE BENEFITS PLAN
EMPLOYER INFORMATION
1) Name and Address of Employed
Plan Administrator:
2) Employer's Telephone Number:
3) Employer's Federal Tax ID Number:
4) Plan Number Assigned to Cafeteria
Plan (e.g,, 501 if this is the first ERISA
plan number assigned):
5) 125 Start Date:
6) Effective Date of the Plan:
7) Last Day of the Plan Year:
Subsequent Plan Years:
8) Name and Address of the
Plan Service Provider:
9) Name and Title of Registered Agent
for Service of Legal Process:
10) Affiliated Employers which will participate in the
CITY OF TUSTIN
ARLENE MARKS
300 CENTENNIAL WAY
TUSTIN, CA 92780
(714) 573-3052
95-6000804
01101/02
01/01/02
12/31/02
01101-12/31
CLAIMS PROCESSOR: FLEX
1932 WYNNTON ROAD
COLUMBUS, GA 31999
WILLIAM A HUSTON
CITY MANAGER
Plan:
ONE
11) Employer's Type of Business
OTHER
Amendpgs
ELIGIBILITY
All Employees employed by the Employer shall be eligible to participate under the Plan except the following:
TEMPORARY OR SEASONAL OR NON-REGULAR PART-TIME
An eligible Employee may become a Participant in the Plan:
( ) Immediately, upon the first day of employment (but not prior to the Effective Date of the Plan).
( ) On the day following commencement of employment.
( X ) On the first day of the month following 30 days of employment.
( ) OTHER
provided the Employee completes a Salary Redirection Agreement. However, eligibility for coverage under any given
Benefit Plan or Policy shall be determined by the terms of that Benefit Plan or Policy, and reductions of the Employee's
Compensation to pay Pre-tax or After-tax Premiums shall commence when the Employee becomes covered under the
applicable Benefit Plan' or Policy.
An eligible Employee may become a Participant in the Dependent. Care and/or Medical Expense Reimbursement Plan(s) (if
elected below):
( ) On the same day such Employee is eligible for the Pre-Tax Premium benefits under the Plan.
( ) On the day following commencement of employment.
( ) On the first day of the month following days of employment.
( ) OTHER
provided the Employee completes a Salary Redirection Agreement selecting such benefits.
BENEFITS PROVIDED UNDER THE PLAN
The following Benefit Plans and Policies subject to the terms and conditions of the Plan are available for election by eligible
employees. The maximum a participant can contribute via the Salary Redi.rection Agreement is the maximum aggregate cost of
the Benefit Plans or Policies elected minus any Non-elective Contribution made by the employer. It is intended that such Pre-ta)~
Premium amounts shall, for tax purposes, constitute employer contribution, but may constitute employee contributions for State
insurance law purposes. Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
appendix to this Plan.
( X ) Group Medical Coverage
(x)
( )
(x)
(x)
(x)
( )
(x)
(x)
(x)
(x)
(x)
(x)
(x)
( ) ,.
Vision Care Coverage
Disability Income-Short Term (A&S)
Cancer Insurance
Group Dental Coverage
Group Term Life Insurance
Disability Income-Long Term (LTD)
Intensive Ca re I ns u ran ce
Accident Insurance
Hospital Indemnity Insurance (HIP)
Specified Health Event
Personal Sickness Indemnity (PSI)
Medical Care Expense Reimbursement described in Section 5.01(b) of the Plan, not to exceed $ 5,000 per Plan Year
pursuant to the CITY OF TUSTIN
Medical Care Expense Reimbursement Plan.
Dependent Care Expense Reimbursement described in Section 5.01(c) of the Plan not to exceed $5,000 per Plan Year or
$2,500 for married filing separate returns pursuant to the CITY OF TUSTIN
Dependent Care Expense Reimbursement Plan.
Opt-out Option: See enrollment material.
THE FUNDING AGENT
The Employer selects the following Funding Agent for the Plan (check one):
The Employer, which will comply with the requirements of Section 7.02 of the Plan.
The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive contributions under
the Plan in accordance with Section 7.03 of the Plan.
ADMINISTRATIVE EXPENSES
Administrative Expenses incurred in operating the Plan shall be paid by (check one):
The Employer, except as otherwise noted in the Plan.
The Participants, except as otherwise noted in the Plan.
6 Amendpgs
City of Tustin
RESOLUTION CERTIFICATION
STATE OF CALIFORNIA )
COUNTY OF ORANGE )SS
CITY OF TUSTIN )
RESOLUTION NO. 02-88
I, PAMELA STOKER, City Clerk and ex-officio Clerk of the City Council of the City of
Tustin, California, hereby certifies that the whole number of the members of the City
Council of the City of Tustin is five; and that the above and foregoing Resolution No. 02-
88 was adopted at a regular meeting of the City Council held on the 16th day of
September, 2002, by the following vote:
COUNCILMEMBER AYES:
COUNCILMEMBER NOES:
COUNCILMEMBER ABSTAINED·
COUNCILMEMBER ABSENT:
Thomas, Worley, Bone, Doyle, Kawashima
None
None
None
'~"~Pamela Stoker, City Clerk