HomeMy WebLinkAbout2024-072-06/04/2024-AUTHORIZING THE MAYOR TO EXECUTE CITY-SPONSORED 401(a) RESTATED ADOPTION AGREEMENTSRESOLUTION 2024-072
OF THE COUNCIL OF THE CITY OF FORT COLLINS
AUTHORIZING THE MAYOR TO EXECUTE CITY-SPONSORED
401(a)RESTATED ADOPTION AGREEMENTS
A.In Resolution 2020-077,the City previously established qualified 401(a)
money purchase plans for eligible City employees,including City service area and unit
directors and employees appointed by the City Council,Police employees in the collective
bargaining unit and classified and unclassified management employees.
B.Effective June 1,2020,the City entered into an administrative services
agreement with nationwide Retirement Solutions,Inc.,along with its affiliates and
subsidiaries (collectively,“Nationwide”),to provide administrative,recordkeeping and
custodial services for its City-sponsored retirement plans.
C.With Resolution 2020-077 and Nationwide’s assistance,the City
established the following 401(a)retirement plans (collectively,the “Plans”):
•The City of Fort Collins 401(a)Unclassified Management and Classified
Employees’Plan
•The City of Fort Collins 401(a)Service Directors’and Council Employees’Plan
•The City of Fort Collins 401(a)Police Plan
D.Internal Revenue Service regulations require designation of a Special
Trustee for these Plans.The Special Trustee is the individual responsible for collecting
and remitting contributions to these Plans in a timely manner.Failure to designate a
Special Trustee would otherwise establish a default designation as the individual at the
City who has “ultimate responsibility”for the City as an employer.
E.The departure of the former Special Trustee from the City of Fort Collins
requires designation of a new Special Trustee for the Plans.
F.Adoption of restated plans to designate a new Special Trustee for these
Plans is an administrative action that will have no financial impact on the City or on
benefits provided to participating employees.
G.City staff has recommended approval and authorization to execute the
amended adoption agreements prepared by Nationwide,which accurately comply with
IRS rules and regulations applicable to 401(a)retirement plans.
H.The City’s deadline to restate its plan documents for these Plans is
December 31,2024.
The City Council has determined that execution of the restated adoption
agreements to designate a Special Trustee for these Plans is in the best interests of the
City,and that the Mayor should be authorized to execute the restated adoption
agreements in support thereof.
In light of the foregoing recitals,which the Council hereby makes and adopts as
determinations and findings,BE IT RESOLVED BY THE COUNCIL OF THE CITY OF
FORT COLLINS that the Council authorizes the Mayor to execute on behalf of the City
the restated Adoption Agreements for the City of Fort Collins Unclassified Management
and Classified Employees’Plan,the City of Fort Collins Service Directors’and Council
Employees’Plan,and the City of Fort Collins Police Plan,attached hereto as collective
Exhibit “A.”
Passed and adopted on June 4,2024.
Effective Date:June 4,2024
Approving Attorney:Aaron Gum
AATTEST:
Interim City Clerk
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Govern mental 401(a)
ADOPTION AGREEMENT FOR
NATIONWIDE FINANCIAL SERVICES,INC.
NON-STANDARDIZED
GO~’ERNNIENTAL 401(a)PRE-APPRO~’El)PLAN
CAUTION:Failure to properly fill out (his Adoption Agreement may result in disqualification of the Plan.
EMPLOYER INFORMATION
(An amendment to the Adoption Agreement is not needed solely to reflect a change in this Employer Information Section
EMPLOYERS NAME.ADDRESS.TIELIEPFIONE NUMBER.TIN AND FISCAL YEAR
Name:City of Fort Collins
Address:300 LaPorte Avenue
Street
Fort Collins Colorado 80521
City Stale Zip
Telephone:1970)221.6535
Taxpayer Identification Number (TIN):84.6000587
Employers Fiscal Year ends:December 31
2.TYPE OF GOVERNMENTAL ENTITY.This Plan ma)’only be adopted a state or local governmental entity.or agency thereof.
including an Indian tribal government and may not be adopted by an)’other entity.including a federal government and any
agency or instrumentality thereol
a I I State government or state agency
b County or count)agency
c ~Xj Municipalityormunicipal agency
d Indian tribal government (see Nole below)
NOTE.An Indian tribal government may onl)adopt this Plan if such entity is defined under Code §770l(aX40).is a subdivision
of an Indian tribal government as determined in accordance with Code *7871(d).or is an agency or instrumentality of either.and
all of the Participants under this Plan employed by such entity substantially perform services as an Employee in essential
governmental functions and not in the performance ofcommereial activities (whether or not an essential government function)
3.PARTICIPATING EMPLOYERS (Plan Section 1.39).Will any other Employers adopt this Plan as Participating Employers?
a.[I No
b.IX)Yes
MULTIPLE EMPLOYER PLAN (Plan Article XI).Will any Employers who are not Affiliated Employers adopt this Plan as part
of a multiple employer plan (MEP)arrangement?
c.[X)No
d.J Yes (Complete a Participation Agreement for each Participating Employer.)
PLAN INFORMATION
(An amendment to the Adoption Agreement is not needed solely to reflect a change in the information in Question 9.)
4.PLAN NAME:
City olFort Collins Unclassified Management and Classified Emolovees’Plan
5.PLAN STATUS
a.)New Plan
b.IX)Amendment and restatement of existing Plan
CYCLE 3 RESTATEMENT(leave blank if not applicable)
I.[)This is an amendment and restatement to bring a plan into compliance with the legislative and regulatory
changes set forth in IRS Notice 2017-37 (i.e..the 6-year pre-approved plan restatement cycle).
6.EFFECTIVE DATE(PIan Section 1.16)(complete a.if new plan:complete a.AND b.if an amendment and restatement)
Initial Effective Date oF Plan (e~cccpt for restatements.cannot be earlier than the first day of the current Plan Year)
a.December I.1974 (enter month da).year)(hereinafter called the “Effective Date”unless 6.b is
entered below)
C 2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
e.[J After-tax voluntary Employee contributions
C.(XJ Rollover contributions (QUeStiOn 36)
PRIOR CONTRIBUTIONS
The Plan used to permit.but no longer does,the following contributions (choose all that apply.Iran))’
g.I Employer matching contributions
h.Employer contributions other than matching cootnbutions
I.I I Rollover contributions
j.[I After-tax voluntary Employee contributions
ELIGIBILI’fl REQUIREMENTS
12 ELIGIBLE EMPLOYEES (Plan Section 1.17)means all Employees (including Leased Employees)EXCEPT those Employees
“ho are excluded below or elsewhere in the Plan;(select a.or b.)
a.I No excluded Employees.There are no additional excluded Employees under the Plan (skip to Question 13).
b.IXI Exclusions.The following Employees are not Eligible Employees for Plan purposes (select onc or more):
I.I I Union Employees (as defined in Plan Seclion 1.17)
2.I I Nonresident aliens (as defined in Plan Section 1.17)
3.I I Leased Employees (Plan Section 1.29)
4.I I Part-time Employees.A part-time Employee is an Employee whose regularly scheduled service is less than
—Hours of Service in the relevant eligibility computation period (as defined in Plan Section 155)
5.J Temporary Employees.A temporary Employee is an Employee who is categorized as a temporar>Lmployee
on the Employer’s payroll records.
6.I I Seasonal Employees.A seasonal Employee is an Employee who is categorized as a seasonal Employee on
the Employer’s payroll records.
7.{X~Other:See Addendum I (must be definitely determinable under Regulation §1.401-1(b)Lxclusions ma>
be employment title specific but may not be by individual name)
NOTE:Ifoption 4.-6.(part-time.temporary and/or seasonal exclusions)is selected,when an>such e’ccluded Employee
actually completes I Year of Service,then such Employee will no longer be part olthis excluded class For this
purpose.the Hours of Service method will be used for ihe I Year of Service override regardless olany contrary
selection at Question 16.
13.CONDITIONS OF ELIGIBILITY (Plan Section 31)
a I I No age and service required.No age and service required for all Contribution ‘lypes (skip to Question 14)
b.(XI Eligibility.An Eligible Employee will be eligible to participate in the Plan upon satisfaction oIthe 1oIlo~~tng (complete
c.and d .select e and f if applicable)
Eligibility Requirements
{Xj Age Requirement
I.IXI No age requirement
2 j )Age2OI/2
3 I I Age2l
4 1 I Age (may not exceed 26)
d [XI Service Requirement
I.[J No service requirement
2 [X)six (6)(not to exceed 60)months ofservice (elapsed time)
3.I j I Year of Service
4.I I _______(not to exceed 5)Yeats of Service
5 j I _______consecutive month period from the Eligible Employees employment commencement date and during
which at least ________Hours of Service are completed.
6 I I ______consecutive months ofemploynient.
7.[J Other:____________________________________________(e.g..date on which 1.000 Hours of Service is
completed within the computation period)(must satisfy the Notes below)
NOTE’If c 4 or d 7 is selected,the condition must be an age or service requirement that is definitely detemiinable and may
not esceed age 26 and ma)’not exceed 5 Years of Serv ice.
NOTE:Year of Servtce means Period olService if the elapsed time method is chosen.
Waiver of conditions.The service and/or age requirements specified above will be ‘valved in accordance with the following
(leave blank if there are no waivers of conditions):
e.[If employed on ________________the following requirements,and the entry daLe requirement,will be waived.The
waiver applies to any Eligible Employee unless 3.selected below.Such Employees will enter the Plan as of such date
(select I and/or 2 AND 3 if applicable):
I I J service requirement (ma)let pan-time Eligible Employees into the Plan)
2 [age requirement
3 [waiver is for
2020 Nationwide Financial Services.Inc or its suppliers
3
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go’ernmental 401(a)
3 For eligibility purposes,the computation period will be as defined in Plan Section 1.55 (i.e..shift to the Plan Year it’
the eligibility condition is one (I)Year olService or less).
4.For vesting,allocation,and distribution purposes,the computation period ~vill be the Plan Year.
5.Upon an Employees rehire,all prior service with the Employer is taken into account for all purposes.
a.{XJ Elapsed time method.(Period of Ser~ice applies instead of Year of Senice)Instead of Hours of Service,elapsed time
will be used for
I.IX!all purposes (skip to Question 17)
2.I J the following purposes (select one or more):
a.I J eligibility to participate
b I I vesting
c.f j allocations,distributions and contributions
b.I J Alternative definitions for the Hours of Service method.Instead of the defaults,the following alternatives ~~ill apply
for the Hours of Service method (select one or more):
I.I I Eligibility computation period.Instead of shifting to the Plan Year,the eligibility computation penod after
the initial eligibility computation period will be based on each anniversary of the date the Employee first
completes an Flour of Service
2.I I ~‘esting computation period.Instead of the Plan Year.the vesting computation period ~~ill be the dale an
Employee first performs an Flour of Service and each anniversary thereof
3.I J Equivalency method.Instead of using actual Flours of Service,an equivalency method will be used to
determine hours of Service for:
a.I I all purposes
b.I I the following purposes (select one or more):
I.J eligibility io participate
2.1 I vesting
3.I J allocations,distribution and contributions
Such method will apply to:
c I )all Employees
d.Employees for ~vbom records of actual Flours of Service are not maintained or available
(e.g..salaried Employees)
e.[I other:____________________________________________________(e.g.per-diem Employees only)
I lours of Service will be dctertnined on the basis of:
I days worked (10 hours per day)
g.I J weeks worked (45 hours per week)
h.I I semi-monthly payroll periods worked (95 hours per semi-monthly pay period)
I.I j months ~vorked (190 hours per month)
I I bi-wcekly payroll periods worked (90 hours per bi-weekl>pay period)
k.I I other:_______________________________________________(e.g..option f.is used for per-diem
Employees and option g.is used for on-call Employees).
4.I I Number of hours of Service required.Instead of 1.000 Flours of Service.Year of Service means the
applicable computation period during which an Employee has completed at least (not to e\ceed
1.000)hours olService for:
a.(j all purposes
6.I I the following purposes (select one or more):
I.I eligibility to participate
2 I I vesting
3.1 I allocations,distributions and contributions
c [J Alternative ror counting all prior service,Instead of the default which recognizes all prtor service for rehtred
Employees,the Plan will not recognize prior service and rehired Employee are treated as new hires for the following
purposes:(select one)
I.)all purposes
2.I the following purposes (select one or more)
a.[j eligtbility to participate
b.[J vesting
c.[)sharing in allocations or contributions
2020 Nationwide Financial Services.Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(i)
Years (or Periods)of Service Percenlage
_______%
0.0
NOTE:I l’any Parl-time/SeasonaV[empora~Employees ‘she are not co’ered under Social Security are participating in this
Plan as a Social Security Replacement Plan,an)contributions used to satisfy the minimum contribution requircmcnts
of Question 24.e.will be 100%vested.
l~VESTING ONIONS
Eteluded vesting service.The foIlo~~ing Years ot’Scrvice ~vill be disregarded for vesting purposes (seleci all that apply:leave
blank if none appl>)
a.[I Service prior to the initial l’flèctive Date of the Plan or a predecessor plan (asdefined in Regulations §1.41 l(a)-5(b)(3))
b j Service prior to the computation period in which an Employee has atiained age
c (Service during a period for which an I mployee did not make mandaior~Fmployee contributions.
%csting for death,Total %nd Permaaent Disabilily and Early/Normal Retirement.Regardless of the vesting schedule,a
Participant will become l’utl~Vesied upon (select all thai apply:lease blank ii none app1>)
d I Death
e J Total and Permanent Disability
f I I Earl)Reiirement Date
g I I Normal Retirement Age
RETIREMENT iCLS
19 NORMAL RLTIRrMI’Nl AGE (“NRA”)(l’lan Section 1.33)means.19
This Question 19 and Question 20 may be skipped if the Plan does not base any benefits,distributions or other features on
Normal Retirement Age.
a.IX)Specific age.11w date a Participant attains age _j~_
h I I ~ge/panicipation.‘[he later of the date a Participant attains age or the anniversary of the first day of
the Plan Year in which partictpation in the Plan commenced
c Othcr:____________________(must be definitely determinable)
NOTI:If this isa Money Purchase Pension Plan and in-service distribuiions at Normal Retirement Age are permitted.then the
Normal Retirement Age cannot be less than age 62.or age 50 ii substantially all Participatits are qualified public safet)
employees (as defined in Code §72(txl )).The “substaniially all”requirement for qualified public safety employees will
no longer be a requirement as of the effective date of the final regulations once the3 are issued &effective If an age
less than 62 is inserted (unless the age 50 safe harbor is applicable for a qualified public safety employee),no reliance
will be afforded on the Opinion Letter issued to the Plan that such age is reasonably representative of the typical
retirement age for the industry in which the Participants works.Effective for Employees hired during Plan Years
beginning on or afler the later of(l)January I.2015.or (2)the close of the first legislative session of the legislative
body with the authority to amend the plan that begins on or after the date that is three (3)months after the final
regulations are published in the Federal Register.an NRA of less than age 62 must comply with the final regulations
under §401(a).
Qualified public safety employees.Normal Retirement Age for public safety employees (as defined in Code §72(t)(l))(leave
blank if not applicable)
d ()Age ______(may not be less than 50 for a Money Purchase Pension Plan or 40 for a ProfIt Sharing Plan)
20 NORMAL RETIREMENT DAlE (Plan Section I 34)means,with respect to any Participant,the.
a.(Xi date on which the Participant attains “NRA’
b I I first day of the month coinciding ~viih or next following the Participant’s “NRA”
e.(j firsi day of the month nearest the Participant’s “NRA”
d.I I Anniversary Date coinciding with or next following the Participant’s “NRA”
e j )Anniversary Dale nearest the Participant’s “NRA”
f I J Other’________________(e.g..first day of the month following the Participant’s “NRA”)
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 40 1(a)
2.I J Regular pay will be excluded
3.I ]Leave cash-outs will be excluded
4.[X~Nonqualified unfunded deferred compensation will be excluded
5.j J Military Ditterential Pay will be included
6.(I Disabilit>continuation payments will be included for all Participants and the salary continuation will continue
for the following fixed or determinable penod
e.f Other ____________________(must be definitely determinable)
CONTRIBI TIONS AND jILOCATIONS
24 EMPLOYER CONTRIBI.TIONS (OTHER THAN MATCIlING CONTRIBUTIONS)(Plan Section 4 I (bX3))(skip to Question
26 if Employer contributions are NOT selected at Question I lb.)
CONTRIBUTION FORM LA (select one or niole of the following contribution formulas:)
a I I Discretionary contribution (no groups).(ma)not be elected if this Plan is a Money Purchase Pension Plan)The
Lmploycr may make a discretionary contribution.to be determined by the Employer.Any such contribution will be
allocated to each Participant eligible to share in allocations in the same ratio as each Participants Compensation bears
to the total of such Compensation of all Participants.
b.I I Discretionary contribution (Grouping method).(may not be elected if this Plan is a Money Purchase Pension Plan)
The Employer ma>designate a discretionary contribution to be made on behalf of each Panicipani group selected
below (001)select I.or 2.).The groups must be clearly defined in a manner that ~~ill not violate the definite
predetermined allocation formula requirement of Regulation §1 40l-l(b)(I )(ii).The Employer must notify the I rustee
in writing of the amount of the Employer Contribution being given 10 each group.
I.I Each Participant constitutes a separate classificaiion.
2 1 I Participants will be divided into the following classifications with the allocation methods indicated under
each classilieation.
Definition of classifications.Define each classification and specify the method of allocating the contribution
among members of each classification Classifications specified below must he clearly defined in a manner
that will not violate the definitely determinable allocation requirement of Regulation §1 401 .l(bXl )(ii)
Classification A witl consist of __________________________________________
The allocation method will be:I I pro rata based on Compensation
I equal dollar amounts (per capita)
Classification B will consist of _______________________________________________
The allocation method will be:I J pro rata based on Compensation
I I equal dollar amounts (per capita)
Classification C will consist of _______________________________________________
The allocation method ‘sill be I I pro rata based on Compensation
equal dollar amounts (per capita)
Classification D will consist of _______________________________________________
The allocation method will be I J pro rota based on Compensation
I equal dollar amounts (per capita)
Additional Classifications ___________________________________________(specify the classifications and which
of the above allocation methods (pro rata or per capita)will be used for each classification)
%OTE:If more than four (4)classifications,the additional classifications and allocation methods may be
attached as an addendum to the Adopt ion Agreement or may be entered under Additional
Classifications above
DetermInation of applicable group.If a Participant shifts from one classification to another during a Plan
Year.then unless selected below,the Participant i tn a classification based on the Participant’s status as of
the last day of the Plan Year.or if earlier.the date of termination of employment.If selected below,the
Administrator will apportion the Participant’allocation during a Plan Year based on the follossing:
a.(}Beginning of Plan Year The classification ~sill be based on the Participant’s status as of ihe
beginning of the Plan Year
b.I )Months in each classification Pro rota based on the number of months the Participant spent in each
classification
c I Days in each classification Pro rata based on the number of days the Participant spent in each
class ilicalion.
d [j One classification only.The Employer will direct the Administrator to place the Participant in only
one classification for the entire Plan Year during which the shill occurs
c IX]Fixed contribution equal to (only select one)’
I [I °oof each Partictpants ompensation for each:
a.I PlanYear
b J calendar quarter
c J month
2020 Nationwide Financial Services.Inc or tts suppliers
9
EXHIBIT A TO RESOLUTION 2024-072
Son-Standardized Governmental 401(a)
NOTE.If a.orc.above is selected,then the mandatory Employee contribution must be picked-up by the
Employer at Question 30.Also.if b.ore.above is selected,then the allocation conditions in Question 25
below do not apply to the Employer contribution made pursuant to ibis provision.
f.I I Other:____________________________(the formula described must satisfy the definitely determinable requirement
under Regulation §1.401-1(b)and if this isa Money Purchase Pension.it must not be a discretionary contribution
formula)NOTE:Under Question 24.1’..the Employer may only describe the allocation of Nonelective Contributions
from the elections available under Questton 24 and/or a combination thereof as to a Participant group or contribution
type (e g.pro rani allocation applies to Group A:contributions to other Employees “ill be allocated in accordance nith
the classifications allocation provisions of Plan Section 4 3 “iih each Participant constttuiing a separate classification)
ALLOCATION CONDITIONS (Plan Section 4.3).1f24.a.b.c.or f is selected above,indicate requirements to share in
allocations of Employer contributions (select a.OR b.and all that apply at c -e)
a.(Xi No conditions.All Participants share in the allocations regardless of service completed during the Plan Year or
employment status on the last day of the Plan Year (skip to Question 26)
b.I Allocation conditions apply (select one of I.-5.AND one of 6.-9.beIo~)
Conditions for Participants NOT employed on the last day olthe Plan lear
I.(A Participant must complete at least __________(not to exceed 500)llours ofScnice if the actual
hours/equivalency method is selected (or at least (not to e’weed 3)months of service if the elapsed
time method is selected).
2.I I A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
3.I I Participants will NOT share in the allocations,regardless of service
4.I I Participants will share in the allocations,regardless of service
5.(I Other:___________________________(must be definitely determinable and not subject to Employer
discretion)
Conditions for Participants employed on the last day or the Plan lear
6 No service requirement.
7.I I A Participant must complcic a Year of Service (or Period of Service if the elapsed time method is selected)
8.I A Participant must complete at least _______Flours of Service during the Plan Year
9.Other:______________________________(must be definitely determinable and not subject to Employer
discretion)
Waiver of conditions for Participants NOT employed on the last day of the Plan lear.If b I .2..3,or 5.above is selected,
Participants who are not employed on the last day ol’the Plan Year in ‘~hich one of the following eventsoccur will be eligible to
share in the allocations regardless of the above conditions (select all that apply.leave blank ilnone apply)
c.I Death
4.I I Total and Permanent Disability
e Termination of employ ment on or after Normal Retirement Age
I.I I or Early Retirement Date
26 EMPLOYER MATCHING CONTRIBI TIONS (Plan Section 4.I(b)(2)and Plan Section 4.12).(skip to Question 29 ifmatching
contributions are NOT selected at Question II .c )The Employer will (or may with respect to an)’discretionary contribution)
make the following matching contributions
A Employee contributions taken into account.For purposes of applying the matching contribution provisions below,the
following amounts are being matched (hereafter referred to as “matched Employee contributions”(select one or more).
a J Llective deferrals to a 457 plan.Enter Plan name(s).
b Elective deferrals to a 403(b)plan.Enter Plan name(s)’_____________________
c Voluntary Employee Contributions
d.(Other:____________________(specify amounts that are matched under this Plan and are provided for within this
Adoption Agreement)
B ~latching Formula.(select one)
e [J Fixed -uniform rate/amount.The Employer will make matching contributions equal to ,_,,,,,,%(e.g..50)of the
Participant’s “matched Employee contributions”
I (that do not exceed %of a Participant’s Compensation (leave blank if no limit)
Additional matching contribution (choose 2 if applicable).
2.1 I plus an additional matching contribution of a diseretionaiy percentage determined by the Employer.
a J but not to exceed ,%of Compensation Such contribution is subject to the Instructions and
Notice requirement of Section 4 12
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 4O1(a)
amount oldie contribution,The tiers may be based on the rate of a Pat’ticipanCs “matched Employee contributions”or
Years of Service.Such contribution is subject to the Instructions and Notice requirement olSeciton 4.12
NOTE:Fill in only percentages or dollar amounts,but not both If percentages are used.each tier represents the amount
of the Participants applicable contributions that equals the specified percentage of the Participant’s Compensation (add
additional tiers if necessary):
Tiers of Contributions Matching Percentage
(indicate $or°/o)
First
Next _______
Next ______
Next ______________
I I Other:_____________________________________(the formula described must satisfy the definitely determinable
requirement under Regulation §1.401-1(b)and if this is a Money Purchase Pension Plan,it must not be a discretionary
contribution formula.NOTE:Under Question 26.B j..the Employer may only describe the allocation ol’Matching
Contributions from the elections available under Question 26 and/or a combination thereof as to a Participant group or
contribution type (e.g..fixed uniform rate applies to Group A:contributions to other Employees will be allocated as a
tiered contribution.)
27 MATChING CONTRIBUTION PROVISIONS
A Maximum matching contribution.The total matching contribution made on behalf of any Participant for any Plan Year will not
exceed:
a.[I N/A (no Plan specific limit on the amount of matching contribution)
b[j S___
c.I I ______%of Compensation.
B.Period of determination.Any matching contribution other than a “Flexible Discretionary Match”~vtll be applied on the
following basis (and “matched Employee contributions and any Compensation or dollar limitation used in determining the
matching contribution will be based on the applicable period Skip if the only Matching Contribution is a Flexible Discretionary
Match.)’
d.(J the Plan Year (potential annual true-up required)
e.)each payroll period (no true-up)
1.I each month (potential monthly true-up required)
g.each Plan Year quarter (potential quarterly true-up required)
h.each payroll unit (e.g..hour)(no true-up)
I I Other (specify):The time period described must be definitely determinable
under Treas.Reg §1.401-1(b)Thi line may be used to apply diftereni options to different matching contributions
(e.g..Discretionary matching contributions will be allocated on a Plan Year period while fixed matching contrtbuttons
will be allocated on each payroll period.)Such contribution period is subject to the Instructions and Notice requirement
of Section 4.12.
28 ALLOCATION CONDITIONS (Plan Section 4.3)Select a.OR b.and all that apply of c.-h.
a.[J No conditions.All Participants share in the allocations regardless of service completed during the Plan Year or
employment status on the last day of the Plan Year (skip to Question 29).
b.I I Allocation conditions apply (select one of I -5.AND one of 6.-9.below)
Condition!for Participants NOT employed on the last day of the Plan lear.
I I A Participant must complete more than _______Hours of Service (or ______months of service if the elapsed
time method is selected)
2 j A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
3 I J Participants will NOT share in the allocations,regardless of servtce.
4 I J Participants will share in the allocations,regardless of service.
5 {I Other _____________________________________(must be definitely determinable)
Conditions for Participants employed on the last day of the Plan Year
6 L I No service requirement
7 1 I A Participant must compleic a Year of Service (or Period of Service if the elapsed time method is selected).
S [J A Participant must complete at least Hours of Service during the Plan Year
9 I I Other (must be definitely determinable and not subject to Employer discretion)
%%aiver of conditions for Participants NOT employed on the last day of the Plan lear.I fb I..2.,3.,or 5.is selected.
Participants who are not employed on the last day of the Plan Year in which one of the following events occur ~viII be eligible to
share in the allocations regardless of the above conditions (select all that apply:leave blank if none apply)
c ]Death
d Total and Permanent Disability
e I I Termination ofemployment on or after Normal Retirement Age
I.I J or Early Retirement Dale
2020 Nationwide Financial Services,Inc or its suppliers
13
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
e j annuity._________________________________________(describe the form ofannuity or annuities)
I’.jXj other:An~other seauence as requested by the Palicinant (must he definitely determinable and not subject to
Employer discretion)
NOTE:Regardless of the above,a Participant is not required to request a ~.ithdrawal of his or her total Account for an
in-service distribution,a hardship distribution,or a distribution from the Participant’s Rollover Account
Cash or property.Distributions may be made in:
g.I I cash only.except for (select all that apply:leave blank if none apply).
I.insurance Contracts
2.I I annuity Contracts
3.I I Participant loans
4.J all investments in an open brokerage window or similar arrangement
h.(XJ cash or property.except that the following limitation(s)apply:(leave blank if there are no limitations on property
distributions):
I.[X~Tax-free distributions glut,to 53.000 Ibr the direct payment of qualifying insurance prenhiums for eligible
retired oublic safet~officers arc available under the Plan (must be definitely determinable and not
subject to Employer discretion)
Joint and SunivorAnnuity provisions.(Plan Sections 6.5(e)and 6.6(e)(select one)The Joint and Survivor Annuity provisions
do not apply to the Plan unless selected belon (choose if applicable)
Joint and Sun’ivor Anauity applicable as normal form of distribution The Joint and Sur~ivor annuity rules set
forth in Plan Sections 6.5(e)and 6 5(t)apply to all Participants (if selected,then annuities are a form oldistribution
under the Plan even if e.above is not selected)
j.[I Joint and Survivor Annuity rules apply based on Participaat election.Plan Section 6.5(I)will apply and lhcjoint
and survivor mles olCode §~40l(a)(II)and 417 (as xci forth in Plan Sections 6.5(c)and 6.6(e)will apply only if an
annuity form oldistribulion is selected by a Participant.
1%ND.it’i.orj.is selected above,the one-year marriage rule does not apply unless selected belou (choose if applicable).
I.I I The one-year marriage rule applies
Spousal consent requirements.Spousal consent is not required for any Plan provisions (except as otherwise elected in i.above
for the joint and survivor annuity rules)unless selected bclo’~(choose ilapplicable)
k.I I Required for all distributions.A Spouse must consent to all distributions (other than required minimum distributions)
I J Beneficiary designations.A married Participants Spouse “ill be the Beneficiary of the entire death benefit unless the
Spouse consents to an alternate Beneficiary.
AND,irk or I is selected,the one-year marriage rule does not apply unless selected bclow (choose if applicable)
I I The one-year marriage rule applies.
32.CONDI1’IONS FOR DISTRIBUTIONS UPON SEVERANCE OF EMPLOYMCN I’Distributions upon severance of
employment pursuant to Plan Section 6.4(a)will not be made unless the following conditions have been satisfied
A.Accounts in excess of 55,000
a.LXI Distributions may be made as soon as adntinistratively feasible following severance of employ ment
b.[Distributions may be made as soon as administratively feasible after the last day of the Plan Year coincident with or
next following severance ofemployment.
c.J Distributions may be made as soon as administratively feasible afler the last day of the Plan Year quarter coincident
with or next following severance ofemploynient.
d.I I Distributions may be made as soon as administratively feasible after the Valuation Date coincident with or next
following severance of employment.
e.I I Distributions may be made as soon as administratively feasible after months have elapsed following severance
of employment.
I’.[I No distributions may be made until a Participant has reached Early or Normal Retirement Dale.
g.)Other:______________________________________(must be objective conditions which are ascertainable and may not
exceed the limits of Code §401(iXl4)as set forth in Plan Section 67)
B.Accounts of 55,000 or less
h.(XI Same as above
i.I J Distributions may be made as soon as administratively feasible folio”ing severance of employment.
j.I I Distributions may be made as soon as administratively feasible after the last day of the Plan Year coincident with or
next following severance of employment.
k.L J Other:______________________________________(must be objective conditions which are ascertainable and may not
exceed the limits of Code §401(aXl4)as set forth in Plan Section 67)
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
Account restrictions.In-service distributions arc permitted from the followmg Participant Accounts:
b.I I
c.I I
all Accounts
only from the following Accounts (select one or more).
I.(Account attributable to Employer matching contributions
2.[j Account attributable to Employer contributions other than matching contributions
3.[J Rollover Account
4.[Transfer Account
Permitted from the following assets attributable to (select one or both):
a I J non-pension assets
b.I J pension assets (e.g..front a Mone3 Purchase Pension Plan)
S [)Mandatory Emplo>ee Contribution Account
6 I I Other (specify Account(s)and
conditions in a manner that satisfies the definitely detenninable requirement under Regulation §1.401-1(b)
and is not subject to Employer discretion)
limitations.The lbllowing limitations apply to in-service distributions:
d [XJ N A (no additional limitations)
c [j Additional limitations (select one or more):
I I The minimum amount of a distribution is $_______
2.I I No more than ______distribution(s)may be made to a Participant during a Plan Year
3.Distributions may only he made from Accounts which are fully Vested
4.I In-service disiributions may be ntade subject to the following proVI ions.(must satisfy the delinitel>
determinable requirement under Regulation §1.401-1(b)and not be subject to Lmployer discretion).
B.IIARDSIIIP DISJRIBI TIONS (Plan Sections 612)(ma>not be selected tithis isa Money Purchase Pension Plan)
I lordship distributions will NOT be alloncd (except as otherwise permitted under the Plan t~ithout regard to this provision)
unless selected below (leave blank if not applicable)
I I I I tardship distributions are permitted from the following Participant Accounts
I.I I all Accounts
2 I I from the following Accounts (select one or more).
I Account attributable to Employer matching contributions
I Account attributable to Employer contributions other than matching contributions
Rollover Account (if not available at any time under Question 36)
Transfer Account (other than amounts attributable to a money purchase pension plan)
I Mandatory Employee Contribution Account
I Other:______________________________________(specify Account(s)and conditions in a manner
that is definitely determinable and not subject to Employer discretion)
l%OTE:[tardshtp dtstr butions are NOT pertained from a Transfer Account attributable to pension assets (e.g..from a
Money Purchase Pension Plan).
Additional limitations.The following limitations apply to hardship distributions
3 1 I N A (no additional limitations)
4.I I Additional linittations (select one or more):
a I I The minimum amount of a distribution is $______
b [J No more than distribution(s)may be made to a Participant during a Plan Year
c I I Distributions may only be made from Accounts which are fully Vested.
d I A Parttcipant does not include a Former Employee at the time of the hardship distribution
e I Hardship distributions may be made subject to the following provisions:______(must satisfy the
definitely determinable requirement under Regulation §1.401-1(b)and not be subject to Employer
discretion).
Bcaeficiary Hardship.Hardship distributions for Beneficiary expenses are NOT allowed unless otherwise selected
belo”
5 I I Hardship distributions for expenses of Beneficiaries are allowed
Special effective date (may be left blank if effective date is same as the Plan or Restatement Effective Date.
select a.and,if applicable.b.)
a.J elTectiveasof __________________________________
b.I J eliminated effective as of ____________________________
only
a.
C.
d.I
C.I
f I
2020 Nattonwide Ftnanctal Services.Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
Reliance on Provider Opinion Letter.The Provider has obtained from the IRS an Opinion Letter specifying the form of this document
satisfies Code §401 as of the date of the Opinion Utter An adopting Employer may rely on the Providers IRS Opinion Letter oniv to the
extent provided in Rev.Proc.2017-41 or subsequent guidance.The Employer may not rely on the Opinion Letter in certain other
circumstances or with respect to certain qualification requirements.which are specified in the Opinion Letter and in Rev.Proc.201 1-41 or
subsequent guidance.In order to have reliance in such circumstances or with respect to such qualification requirements.the Employer must
apply for a determination letter to Employee Plans Determinations of the IRS.
An Employer who has ever maintained or who later adopts an individual medical account.as defined in Code §41 XIX2))in addition to this
Plan may not rely on the opinion letter issued by the Internal Revenue Service with respect to the requirements of Code*4 15
This Adoption Agreement may be used only in conjunction with the basic Plan document #03.This Adoption Agreement and the basic
Plan document will together be known as Nationwide Financial Services.Inc.Non-Standardized Governmental 40l(a)Pre.Approved Plan
#001.
The adoption of this Plan,its qualification by the IRS.and the related tax consequences are the responsibility of the Employer and its
independent tax and legal advisors.
Execution for Page Substitution Amendment Only.If this paragraph is completed,this Execution Page documents an amendment to
Adoption Agreement Election(s)_______effective ____________.by substitute Adoption Agreement page number(s)________.The
Employer should retain all Adoption Agreement I!,cecution Pagcs and amended pages.(Note:The Efjective Dale gnat be retroactive or may
be prospective.)
The Provider.Nationwide Financial Services.Inc.will notify the Employer of any amendment to this Prc-approved Planorof any
abandonment or discontinuance by the Provider of its maintenance of tins Pre-approved Plan.In addition.this Plan is pnn’ided to the
Employer either in connection with investment in a product or pursuant to a contract or other arrangement for products and/or services.
Upon cessation of such investment in a product or cessation of such contract or arrangement.as applicable,the Employer is no longer
considered to be an adopter of this Plan and Nationwide Financial Services,Inc.no longer has any obligations to the Employer that relate
to the adoption of this Plan.For inquiries regarding the adoption of the Pry-approved Plan,the Providers intended meaning of any Plan
provisions or the effect of the Opinion l.etter issued to the Provider,please contact the Provider or the Providers representative
Provider Name Nationwide Retirement Solutions
Address P0 Box 18279
lunibu IS
Telephone Number 877 496-16 0
Email address (optional)
The Employer,by executing beIo’~.hereby adopts this Plan (add additional signature lines as needed).NOTE:If more than one Plan type is
adopted,the Plan Provider must pros ide multiple plan document fbr Lmployer signature
EIvIPLOYLR:City of Fort Collins
DATE SIGNED
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
Contribution
Eligibility Vesting Allocation
I I Employer name:a.I I b.[I c.I
2.I I Employername:a.I I b.I I c.I I
3.I I Employer name b.I I c.I I
4 I I Employernanie a.{I b.j I c.I
5.I I Employer name:a.I I b.I I c.(I
6.1 I Employer name:a.I b.I J c.I I
Limitations
7.[The following provisions or limitations apply with respect to the a.I b.I I c.I I
recognition of prior service:____________________________________
(c.g..credit service with X only orJfollowing l/t119)
Other vesting provisions.The follo~ving vesting provisions appl)to the Plan (select one or more):
I I 1 Special vesting provisions.The following special provisions apply to the vesting provisions of the Plan:
____________________(must be definitely determinable and satisfy the paramelers set forth at Question I?)
2 I I Pre-amendment vesting schedule.(Plan Section 6.4(b)).If the vesting schedule has been amended and a
different vesting schedule other than the schedule at Question 17 applies to any Participants,then the
follo’sing provisions apply (must select one of a.dj:
Applicable Participants.The vesting schedules in Question I?only apply to:
a.(Participants who arc Employees as of _______________________(enter date).
b.I I Participants in the Plan who havc an [tour of Service on or after ___________________(enter
date).
c.I I Participants (even ilnol an Employee)in the Plan on or after _____________________(enter date)
d.I Other:_________________________(e.g..Participanls in division A.Must be definitely
determinable.)
I I Minimum distribution transitional rules (Plan Section 6 8(eXS))
NOTE:This Section does not apply to (I)a ne’~Plan.(2)an amendment or restatement of an existing Plan that never
contained the provisions of Code §401 (a)(9)as In effect prior to Ihe amendments made by the Small Business
Job Protection Act of 1996 (SBJPA),or (3)a Plan ~~here the transition rules belo”do not affect an>current
ran icipants.
The “required beginning date”for a Participant is.
I I April 1st of the calendar year following the year in whiclt the Participant attains age 70 I 2 (pre-SHJPA rules
continue to apply)
2.I I April 1st of the calendar year following the later of the year in which the Participant attains age 70 I 2 or
retires (the post-SBJPA rules),with ihe following exceptions (select one or both:leave blank if both applied
effective as of January I.1996):
a I I A Participant who was alread>receit trig required minimum distributions under the pre-SBJPA
rule5 as of _______________________________________(ma>not he earlier than January I.1996)
was allowed to stop receiving distributions and have them recommence in accordance with the
post-SBJPA rules.Upon the recommencement of distributions,if the Plan permits annuities as a
form of distribution then the following apply:
I.[I N/A (annuity distributions are not permitled)
2 (Upon the recommencement of distributions.the original Annuity Starling Date will he
retained.
3.I I Upon the recommencement of distributions.a new Annuity Starting Date is created.
b.[J A Participant who had not begun receiving required minimum distributions as of
_______________________________(may not be earlier than January I,1996)may elect to defer
commencement of distributions until retirement The option to defer the commencement of
distributions (i.e .to elect to receive in-service distributions upon attainment of age 70 1/2)applies
to all such Participants unless selected below:
I )The in-service distribution option was eliminated with respect to Participants who
attained age 70 I 2 in or after the calendar year that began after the later of(I)December
31,1998.or (2)the adoption date of the restatement to bring the Plan into compliance
with the SBJPA
tj 2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Ga’ernmental 401(a)
ADMINISTRATIVE PROCEDURES
The follo~~ing arc optional administrative prot isions.The Administrator may implement procedures that ovenide any elections in this
Section “ithout a formal Plan amendment.In addition,modifications to these procedures will nol affect an Employer’s reliance on the Plan
A Loan Limitations.(complete only if loans to Participants art permitted:leave blank if none apply)
a.~Xj I imitations (select one or more):
I.(XJ Loans ~vill be treated as Participant directed investments.
2.{J Loans ~~‘ill only be made for hardship or financial necessity as specified below (select a.or b.)
a.J hardship reasons specified in Plan Section 6 12
b.I J financial necessity (as defined in the loan program)
3.(X)The minimum loan will be $1.000
4.[XJ A Participant may only have one (I)(e.g..one (I))loan(s)outstanding at any lime.
5.1 I All outstanding loan balances will become due and payable in their entirety upon the occurrence of a distributable
eveni (other than satisfaction of the conditions for an in-serb ice distribution (including a hardship distribution).if
applicable).
6.I The home loan term will be —years.(ilnot selected,the Adniinistralor establishes the term for repayment of
a home loan)
7 {Account restrictioas.t.oans will only be permitted from the following Participant Accounts (select all that apply
or leave blank il’no limitations apply)
a.I I Account(s)attributable to Fmployer matching contributions
b.J Account attributable to Employer contributions other than matching contributions
c.Rollover Account
d.I I Transfer Account
e.I I Other:
AND,if loans rut restricted to certain accounts,the limitations olCode §72(p will be applied
f.(j by determining the limits by only considering the restricted accounts.
g.I I by determining the limits taking into account a Participant’s entire interest in the Plan
Additional Loan Provisions (select all that apply:leave blank if none apply)
b.IXI Loan payments.Loans are repaid by (if left blank.then payroll deduction applies unless Participant is not subject to payroll
(e.g..partner who only has a draw)):
I payroll deducuon
2 IXI ACII (Automated Clearing llousc)
3 I I check
a I Only for prepayment
c.~Xi Interest rate.Loans will be granted at the following interest rate (if left blank then 3.below applies)
I IXI ,,j,percentage points over the prime interest rate
2 1 I
3,[j the Administrator establishes the rate at the time the loan is made
d IXI Refinancing.Loan refinancing is allo”ed.
B Life Insurance.(Plan Section 7.5)
a [XI Life insurance may not be purchased.
b I I Lire Insurance may be purchased...
I I at the option of the Administrator
2 I I at the option of the Participant
Limitations
3 I I N A (no limitations)
4 J The purchase olinitial or additional life insurance ~~‘ill be subject to the following limitations (select one or more):
a I Each initial Contract will have a minimum face amount of S______
b I I Each additional Contract will have a minimum face amount of S_______
c F I The Participant has completed —Years (or Periods)of Service.
d I I The Participant has completed ______Years (or Periods)of Service while a Participant in the Plan
o I I The Participant is under age _______on the Contract issue date.
f I I The ma’cimum amount of all Contracts on behalf of a Participant may not exceed $______
g j The ma.’~imum face amount of any life insurance Contract will be $
C.Plan Expenses.Will the Plan assess against an indi’idual Participant’s Account certain Plan e’pcnscs that are incurred by.or are
attributable to.a particular Participant based on use of a particu ar Plan service9
a I JNo
b [XI Yes
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
son-Standardized Governmental 4Ol(a~
b jXJ Complete the following UNLESS not selecting supporting Coons:
Trustee/Insurer (se/cc’a.OR one or more of ci.-e.)
c.j J Insurer.This Plan is Ijinded exclusively with Contracts (select one or more of I -4)
Name of Insurer(s)
I.I I _______________
2.(___________
3.J Use Employer address/telephone number/email
4.J Use lollowing address/telephone number/entail
a.Street:_________________________________
b.City:
c.State:______________________________
d.Zip:
e.Telephone:
C Email:___________________________
d.I }Individual Trustee(s)
e.IXI Corporate Trustee
Name of ‘Irust
Specify name of Trust (required for P15 (rust):City of Port Collins Unclassified Management and Classified tmnlovecs’
Plan
Individual ‘I’n,stees (ird.selected above,complete g.—j.)
Directed/Discretionary Trustees.The individual Trustee(s)executing this Adoption Agreement art (select g orb
g.Select for each individual Trustee (skip to next question)
Ii.(I The lotlowing selections apply to all individual Trustee(s)(select I.-4.as applicable)
A discretionary Trustee overall plan assets (may not be selected with 2 -4)
2 I J A nondiscretionary (directed)Trustee over all plan assets (may not be selected ~vith I -3 or 4
3.I I The individual ‘I’rustee(s)will serve as a discretionary Trustee over the followtng assets:___________________
(may not be selected with I.or 2.)
4.I I The individual Trustee(s)will serve as a nondiscretionary (directed)Trustee over the following assets:
____________(may not be selected with I.or 2.)
Individual Trustee(s)(complete if d selected above)
I f Individual Trustee(s)are (select one or more ola -j :enter address at j below)
a.Name ___________
Title/Email~
I Title __________
2 Email ____________(optional)
Trustee is:(complete iIg selected above:select 3 6 as applicable)
3 I J Discretionary Trustee over all plan assets (may not be selected with 4.6.)
4 I I A discretionary Trustee over the following plan assets:___________(may not be select with 3.or 5.)
5 I )Nondiscrettonary Trustee over all plan asseis (may notbe selected with 3..4.or 6.)
6 [A nondiscrettonary (directed)Trustee or Custodian over the following plan assets ___________(may not he
selected with 3 cr5.)
b Name ________
Title/Email:
I ThIe______
2 Email ___________(optional)
Trustee is:(complete if g.selected above,select 3 6.as applicable)
3 1 I Discretionary Trustee over all plan assets (may not be selected with 4.—6.)
4 I )A discretionary Trustee over the following plan assets’(ma>not he select with 3.or 5.)
S I I Nondiscretionary Trustee over all plan assets (may not be selected with 3..4.or 6.)
6 J A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(ma)’not be
selected with 3.or 5)
c.Name __________
Title/Email:
I.Title _______
2.Email ___________(optional)
Trustee is:(complete if g selected above;select 3.6.as applicable)
3 1 I Discretionary Trustee over all plan assets (may not be selected with 4.6.)
4 I A discretionary Trustee over the following plan assets:(may not he select wtth 3 or 5)
2020 Nationwide Financial Services.Inc.or its suppliers
3
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
4.1 I A discretionary Trustee over the follo~iing plan assets:(may not be selected with 3.or 5.)
5.j Nondiscrettonaiy Trustee over all plan assets (may not be selected with 3..4.or 6.)
6.1 A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(ma)not be
selected with 3.or 5.)
j.Name ________
Title/Email:
I.Title _______
2.Email ___________(optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3.I I Discretionary Trustee over all plan assets (may not be selected ~ith 4.or 6.)
4.1 I A discretionary’Trustee over the following plan assets:(may not be selected with 3.or 5.)
5.Nondiscretionary Trustee over all plan assets (may not be selected with 3..4.or 6.)
6.)A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(ma)not be
selected with 3.or 5.)
j.Individual Trustee Address (complete if d.selected above)
I.j Use Employer address/telephone number email
2.Use thilowing address/telephone number email
a,Street:
b.City:__________
c.State:___________
d.Zip:
e,Telephone:
f.Email:___________
Corporate Trustee Name/Type/Address (complete lie,selected above)
k.IX!Name Nationwide Trust Conmany,FSB
Address/telephone number/email
I.f Use Employer address/telephone number email
2.IX I Use following address/telephone number email
a.Street:10 West Nationwide Blvd.
b.City:Columbus
c.State Ohio
d.Zip:43215
l’elephone (877)496-1630
i Ematl O3gT
Directed/Discretionary.The Corporatc Trustee is (select 3 -6 as applicable)
3.I I A discretionary Trustee over all plan assets (may not be selected with 4 6
4.IX!A nondiscretionary (directed)Trustee over all plan assets (may not be selected with 3..5.or 6.)
5.I I A discretionary Trustee over the following plan assets over the following assets.____________(may not be
selected with 3 4
6.I j A nondiscretionary (directed)irustee over the following plan assets ________(may not be selected with 3
4)
Signet (optional):
1 I I Name of person signing on behalf of the corporate Trustee
S I I Email address ol’person signing on behalf oithe corporate Trustee
Special Trustee for collection of contributions.The Fmployer appoints the following Special Trustee with the responsibility to
collect delinquent contributions (apilonal)
I.(XI Name Randy Bailey
Title:
I.Director.Accounting
Address/telephone number/email
2.1 I Use Employer address/telephone number email
3.IXI Use following address/telephone number email
a Street 215 N Mason St
b.City:Fort Collins
c.State:Colorado
d Zip:80524
e.Telephone:(970)416-4354
f Email:rbaileva.fcgov,com
Custodian(s)Name/Address.The Custodian(s)are (api lanai)
rn,I J Same(s)
2020 Nationwide Financial Services.Inc.or its suppliers
5
EXHIBIT A TO RESOLUTION 2024-072
Non-Slandardized Cow ernmtntal 40 1(a)
City of Fort Collins Unclassified Management and Classified Employees’Plan
Addendum I
Nationwide-Sponsored Non-Standardized Governmental Defined Contribution Pre-Approved Plan
The following provisions are incorporated into Question 12 of the Adoption Agreement as of September 18,2020:
Section 12(bfth)Eligible Employees shall be updated to reflect the following.
An Eligible Employee for Plan Purposes shall mean any person employed in the follo’~irtg Eligible Groups
•Unclassified Managers ~“ho elected to remain in the General Employees’Retirement Plan (GERP)on January I,2011
•Unclassified Managers who elected to freeze their benefits tn GERP on January I.2011
•Unclassified Managers hired after January I.1999 but before April I.2007 not participating in GCRP
•Unclassified Managers hired on or after April 1.2007
•Director of Administrative Services of Poudre Fire Authority hired before June I 020
•Unclassified Managers hired on or before January I.1999 not participating in GFRP
•Classified City Employees (except Community Service Officers)hired on or after January I.1999 but prior to April 1.2007
not participating GERP
•Community Service Officers
•Classified City Employees (except Community Service Officers)hired before April 1.2007 not participaling in GERP
•Classified City Employees (except Community Service Officers)participating in GLRP and the Money Purchase Plan
•Classified City Employees (except Community Service Oflicers)participating GI3RP and not in the Money Purchase Plan
•Classified City Employees hired on or after April I.2007 participating in the Money Purchase Plan
a Classified PFA Employees not participating in GERP and participating in the Money Purchase Plan for PM
The following provisions are incorporated into Question 24 of the Adoption Agreement as of September 18,2020:
Section 24(aX4)Fixed Employer Contribution (Oilier than Matching Contributions)shall be updated to reflect the following.
The Employer will make the following contributions contributed on a bi-weekl>basis for
a Unclassified Managers who elected to freeze their benelits in GERP on January I.2011;7.5%ofCompensation
•Unclassified Managers hired after January I.1999 but before April 1.2007 not participating in GIRP 7 5°oofCompensation
•Unclassified Managers hired on or after April I.2007 6.5%olCompensation
•flirectorofAdministrative Services of Poudre Fire Authority hired before June 1.2020.7.5°.of Compciisaiion
•Unclassified Managers hired on or before January I.1999 not participating in GERP 3%olCompensalion
•Classified City Employees (except Community Service Officers)hired on or after January I.1999 but prior to April I.2007 not
participating GERP 7 5%of Compensation
•Community Service Officers 8%of Compensation
•Classified City Employees (eNcept Community Ser~ice Officers)hired before April I.2007 not participating in GLRP 4.5%of
Compensation
a Classified City Employees hired on or after April 1.2007 participating in the Money Purchase Plan 6 5%of Compensation
a Classified PFA Employees not participating in GERP and participating in the Money Purchase Plan for PEA 7 5%of
Compensation
The following Employee Groups will not receive an allocation of Employer Contributions:
a Unclassified Managers who elected to remain in the (‘,eneraj Employees’Retirement Plan (GERP)on January 1.2011
a Classified City Employees (except Community Service Officers)participating in GERP and the Money Purchase Plan
a Classified City Employees (except Community Service Officers)participating GERP and not in the Money Purchase Plan
The following provisions are incorporated into Question 30 of the Adoption Agreement as of September t8,2020:
Section 30(c)Amounts of Mandatory Employee Contributions shall be undated to reflect the following:
The following Eligible Employees must contribute 6%of their Compensation on a bi-weekly basis to the Plan:
•Unclassified Managers who elected to remain in the General Employees’RetLrement Plan (GERP)on January I.2011
•Unclassified Managers who elected to freeze their benefits in GERP on January I,2011
•Unclassified Managers hired after January I.1999 but before April 1.2007 not participating in GERP
•Unclassified Managers hired on or afler April 1.2007
a Director of Administrative Services of Poudre Fire Authonty hired before June I 2020
2020 Nationwide Financial Services,Inc or its suppliers
7
EXHIBIT A TO RESOLUTION 2024-072
ACCEPTANCE OF SPECIAL TRUSTEE
I.the undersigned,accept the appointment as Special Trustee of the City orrort Collins Unclassified Management and Classified
Employees Plan (Plan),and agree to all of the obligations,responsibilities and duties imposed upon the Special Trustee under the Plan and
Trust.The sole responsibility of the Special Trustee is to collect contributions owed to the Plan.No other Trustee has the responsibility to
collect conlribulions owed to the Plan.
gd.Y8a1ey.5/22/2024
SPCCIAL TRUSTEE DATE SIGNED
EXHI8IT A TO RESOLUTION 2024-072
r’.on-Standardized Governmental 401(a)
Restatement Effective Date.If this is an amendment and restatement,the effective date of the restatement (hereirtafler called the
“Effective Dates)is:
b.Januan I.2024 (enter month day.year.NOTE:The restatement date may not be prior to the first
day of the current Plan Year.Plan contains appropnate retroactive effective dates with respect to provisions Ibr appropriate
laws.)
PLAN YEAR (Plan Section 1.43)means,except as otherwise provided in 4.below:
a [XI the calendar year
b [I the twelve-month period ending on (e.g.June 30th)
SHORT PLAN YEAR (Plan Section t.47).This is a Short Plan Year (if the effective dale of participation is based on a Plan
Year,then coordinate with Question 14):
[XI NA
d.I I beginning on __________________________(enter month day.year.e.g..July I.2020)
and ending on _____________________________(enter month day.year).
VALUATION DATE (Plan Section 1.53)means:
a.[X]every day that the Trustee (or Insurer),any transfer agent appointed by the Trustee (or Insurer)or the Employer,and
any stock exchange used by such agent are open for business (daily valuation)
b.(J the last day of each Plan Year
c.[J the last day of each Plan Year quarter
d.[I other (specify day or days)____________________________________(must be at least once each Plan Year)
NOTE:The Plan always permits interim valuations.
ADMINISTRATOR’S NAME.ADDRESS AND TELEPHONE NUMBER
(If none is named.the Employer will be the Administrator (Plan Section 1.2).)
a.(XI Employer (use Employer address and telephone number)
b.I The Committee appointed by the Employer (use Employer address and telephone number)
c.(Other:
Name:
Address.
Street
City State Zip
Telephone:
TYPE OF PLAN (select one)
a.(j Profit Sharing Plan.
b (XI Money Purchase Pension Plan.
CONTRIBUTION TYPES
The selections made below must correspond with the selections made under the Contributions and Allocations Section of this
Adoption Agreement.
FROZEN PLAN OR CONTRIBUTIONS HAVE BEEN SUSPENDED (Plan Section 4.1(c))(optional)
a.I I This is a frozen Plan (i.e.,all contributions cease)(if this is a temporary suspension,select a.2):
I.J All contributions ceased as of,or prior to.the effective date of this amendment and restatement and the prior
Plan provisions are not reflected in this Adoption Agreement (may enter effective date at 3.below and/or
select prior contributions at g.‘j (optional),skip questions 12-18 and 22-30)
2.L I All contributions ceased or were suspended and the prior Plan provisions are reflected in this Adoption
Agreement (must enter effective date at 3 below and select contributions at b.-f.)
Effective date
3.[)as of _______________________________________(effective dale is optional unless a.2 has been selected
above or this is the amendment or restatement to freeze the Plan).
CURRENT CONTRIBUTIONS
The Plan permits the following contributions (select one or more):
b.[Xi Employer contributions other ban matching (Questions 24-25)
I.I I This Plan qualifies as a Social Security Replacement Plan (Question 24.e must be selected)
c.IX)Employer matching contributions (Questions 26-28)
d [J Mandatory Employee contributions (Question 30)
2020 Nationwide Financial Services,Inc or its suppliers
2
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
2.[J age requirement
3.J waiver is for:____________________________________
Amendment or restatement to change eligibility requirements
I I )This amendment or restatement (or a prior amendment and reslatement)modified the eligibility requirements and the
prior eligibility conditions continue to apply to the Eligible Employees specified below lithis opiion is NOT selected.
then all Eligible Employees must satisfy the eligibility conditions set forth above.
I [)The eligibility conditions above only apply to Eligible Employees who “ere not Participants as of the
effective date of the modification.
2 [J The eligibility conditions above only apply to individuals who were hired on or after the effective date of the
modification.
14 EFFECTIVE DATE OF PARTICIPATION (ENTRY DATE)(Plan Section 3.2)
An Eligible Employee who has satisfied the eligibility requirements will become a Participant in the Plan as olthe:
a.[I dale such requirements are met
b.[I first day of the month coinciding with or next following the date on which such requirements are met
c.[]first day of the Plan Year quarter coinciding with or next following the date on which such requirements are mel
d (}earlier of the first day of the Plan Year or the first day of the seventh month of the Plan Year coinciding ~~ith or next
following the date on which such requirements are met
e I first day of the Plan Year coinciding with or next following the date on which such requirements are met
I I first day of the Plan Year in which such requirements are met
g I )first day of the Plan Year in which such requirements are met,if such requirements are met in ihe first 6 months of the
Plan Year.or as of the first day of the next succeeding Plan Year if such requirements are met In the last 6 months ol
the Plan Year
h LX)other:First Dasroll after mcttäitEliaibilin_(must be definitely determinable)
SERVICE
IS RECOGNITION OF SERVICE WITH OTHER EMPLOYERS (Plan Sections 1.40 and 1.55)
a lxi No service with other employers is recognized except as otherwise required by law (e.g..the Plan already provides for
the recognition of servtce with Employers who have adopted this Plan as well as sen ice with Affiliated Employers and
predecessor Employers who maintained this Plan,skip to Question 16)
b I )Service with the designated employers is recognized as follows (seteci c e aiid one or more of columns I.-3.:chose
other options as applicable)(if more than 3 employers,attach an addendum to the Adoption Agreement or complete
option h.under Section B of Appendix A)
I.2.3.
Contribution
Other Employer Eligibility Vesting Allocation
c.Employername I I I I F I
d ()Employername I I I I I
e I I Employername [)I I I I
Limitations
f [The following provisions or limitations apply with respect 10 the [I I I I
recognition of prior service:__________________________________
(e.g..credit service with X only on/following I 119)
g.)The following provisions or limitations apply with respect to the recognition of service with other employers:_________
(e.g..credit service with X only on/following I I 19 or credit all service with enlities the Employer acquires after
1231 18)
!%OTE:If the other Employer(s)maintained this qualifted Plan,then Years (and/or Periods)of Service with such Employer(s)
must be recognized pursuant to Plan Sections I 40 and I 55 regardless of any selections above
16.SERVICE CREDITING METHOD (Plan Sections 1.40 and 1.55)
NOTE:If any Plan provision is based on a Year of Service,then the provisions set forth in the definition of Year of Service in
Plan Section 1.55 will apply,including the following defaults,except as othenvise elected below:
I A Year of Service means completion of at least 1,000 Hours of Service during the applicable computation period.
2 I-fours of Service (Plan Section 1.24)will be based on actual Hours of Service except that for Employees for whom
records of actual Hout-solService are not maintained or available (e.g..salaried Employees),the monthly
equivalency ~vilI be used
2020 Nationwide Financial Services.Inc or its suppliers
4
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
d.I I Other service crediting provisions:_____________________________________(must be definitely determinable:e.g..
for vesiing a Year olService is based on 1.000 Hours of Service but for eligibility a Year of Service is based on 900
Hours of Service.)
NOTE:Must not list more than 1.000 hours in this Section.This servicing credit provision ‘viii be used for:
I.I I Allpurposes
2.1 )The following purposes (select one or more):
a.I eligibility to participate
b I I vesting
c.j allocations,distributions and contributions
~ESTI’.G
I?VESTING OF PARTICIPANVS INTEREST EMPLOYER CONTRIBUTIONS (Plan Section 6.4(b))
a.I N A (no Employer contributions:skip to Question 19)
b.IX)The vesting provisions selected below apply.Section B of Appendix A can be used to specify any e’cceptions to the
provisions bclo~.
NOTE:The Plan provides that contributions for convened sick leave and/or vacation leave are lull>Vested.
~esting for Employer contributions other than matching contributions
c I I N A (no Employer contributions (other than matching contributions):skip to 1.)
d.(XI 100%vesting.Participants are 100%Vested in Employer contributions (other than matching contributions)upon
entering Plan.
e.J The foflosving vesting schedule.based on a Participant’s Years of Service (or Periods of Service if the elapsed time
method is selected),applies to Employer contributions (other than matching contributions)’
I.)6 Year Graded:0-i year-0%:2 years-20%:3 years-40%;4 years-60%:5 years-80%:6 years-tOO°.
2.[)4 Year Graded:I year-25%;2 years-50%.3 years-75°.:4 years-l00%
3.()5 Year Graded:I year-20%;2 years-40~o.3 years-60°o:4 years-80%:5 years-lOO°o
4.(J Cliff:100%vesting afler _______(not to exceed 15)years
5 (Other graded vesting schedule (must provide for full vesting no later than 15 years of service,add additional
lines as necessary)
Years (or Periods)of Sen ice Percentage
0,,
~csting for Employer matching contributions
f.[j N A (no Employer matching contributions)
g.(Xj The schedule above will also apply to Employer matching contributions.
h )100%vesting.Participants are 100%Vested in Employer matching contributions upon entering Plan.
~.I I The following vesting schedule,based on a Participant’s Years of Service (or Periods of Sen ice ilthe elapsed time
method is selected).applies to Employer matching contributions.
I j 6 Year Graded:0-I year-0%:2 years-20~’o;3 years-40%,4 years-60°..5 years-80%:6 years-I 00%
2 1 I 4 Year Graded:I year-25%;2 years-5O%.3 years-75°o.4 years-I00%
3 [)5 Year Graded:I year-20°e:2 years•40%:3 years-60°o.4 years-SO0.:S years-lOOt.
4 Clim 100°.vesttng after (not to exceed 15)years
5 I I Other graded vesting schedule (must provide for full vesting no later than 15 years of sen ice,add additional
lines as necessary)
t 2020 Nation~~iotFinanctai Services.Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
21 EARLY RETIREMENT DATE (Plan Section 115)
a.IXI N/A (no early retirement provision provided)
b.I Early Retirement Date means the:
I.[)date on which a Participanl satisfies the earl>retirement requirements
2.[)first day of the month coinciding with or next following the date on which a Participant satisfies the early
retirement requirements
3.[I Anniversary Date coinciding with or next following the date on which a Participant satisfies the earl>
retirement requirements
Early retirement requirements
4.(1 Participant attains age
AND,completes....(leave blank if not applicable
a.J at least ______Years (or Periods)of Service for vesting purposes
b.(I at least ______Years (or Periods)of Service for eligibility purposes
c.j Early Retirement Date means _______________________________(must be definitely determinable)
COMPENSATION
22.COMPENSATION with respect to any Participant is defined as follows (Plan Sections 1.10 and 1.23).
Base definition
a.[XI Wages.tips and other compensation on Form W-2
b.[J Code *3401(a)wages (wages for withholding purposes)
c.J 4 15 safe harbor compensation
NOTE:Plan Section 1.10(c)provides that the base definition of Compensation includes deferrals that are not included in
income due to Code **401(k).125.132(0(4).403(b),402(h~IXBySEP).4l4(h)(2).&457
Determination period.Compensation will be based on the following “determination period”(this will also be the Ltmitation
Year unless otherwise elected at option f under Section B of Appendix A)
d.[XI the Plan Year
e I the Fiscal Year coinciding ‘sith or ending ‘~ithin the Plan Year
I I I the calendar year coinciding with or ending within the Plan Year
Adjustments to Compensation (for Plan Section 1.10)Compensation “ill be adjusted by:
g.I I No adjustments (skip to Question 23 below)
h IX!Adjustments.Compensation will be adjusted by (select all that apply):
I [I excluding salary reductions (401(k).125.132(0(4).403(b).SEP.4l4(h)(2)pickup.&457)
2 1 I excluding reimbursements or other expense allowances fringe benefits (cash or non-cash).moving expenses.
deferred compensation (other than deferrals specified in I above)and welfare benefits.
3 1 )excluding Compensation paid during the “determination period”while not a Participant in the Plan.
4.[XI excluding Military Differential Pa>
5.~X]excluding overtime
6.[X]excluding bonuses
7 (J other:__________________________(e.g..describe Compensation front the elections available above or a
combination thereof as to a Participant group (e.g..no exclusions as to Division A Employees and exclude
bonuses as to Division B Employees):and/or describe another exclusion (e.g..exclude shill differential pay)).
23.POST-SEVERANCE COMPENSATION (415 REGULATIONS)
415 Compensation (post-severance compensation adjustments)(select all that apply at a.:leave blank if none apply)
NOTE:Unless otherwise elected under a.below,the following defaults apply:415 Compensation will include (to the exient
provided in Plan Section 1.23).post-severance regular pay,leave cash-outs and payments from nonqualified unfunded
deferred compensation plans.
a.IX)The defaults listed above apply except for the following (select one or more):
I.(j Leave cash-outs will be excluded
2.(XI Nonqualified unfunded deferred compensation will be excluded
3 IX)Disability continuation payments ~~ill be included for all Participants and Ihe salary continuation will
continue for the following fixed or determinable period 12 Monihs
4 j J Other:____________________(must be definitel>determinable)
Plan Compensation (post-severance compensation adjustments)
b.[j Defaults apply.Compensation will Include (to the extent provided in Plan Section 1.10 and to the extent such amounts
wvuld be included in Compensation if paid prior to severance of employment)post-severance regular pay,leave cash-outs.
and payments from nonqualified unfunded deferred compensation plans.(skip to Question 24)
c.[I Exclude all post-severance compensation.Exclude all post-severance compensation for allocation purposes.
d.[XI Post-severance adjustments.The defaults listed at b.apply except for the following (select one or more):
I.I I Exclude all post-severance compensation
t 2020 Nationwide Financial Services,Inc.or us suppliers
8
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 40 1(a)
d.I J pay period
e.(J week
2.(J $_______per Participant.
3.I J $_______per Hour of Service worked while an Eligible Employee
a.(J up to hours (leave blank if no limit)
4.(XI other:10%of Participant’s Comocnsaiion contributed bs-weeklv (the formula described must satisfy the
definitely determinable requirement under Regulation §1401-1(b))NOTE:UnderQuestion 24.c.4..the
Employer may only describe the allocation of Nonelective Contributions from the elections available under
Question 24 c of this Adoption Agreement and/or a combination thereolas to a Participant group (e.g..a
monthly contribution applies to Group A)
d (Sick leave/vacation leave conversion.The Employer will contribute an amount equal to an Employee’s current hourly
rate of pay multiplied by the Participant’s number of unused accumulated sick leave and or vacation days (as selected
below).Only unpaid sick and vacation leave for which the Employee has no right to receive in cash may be included.
In no event will the Employer’s contribution for the Plan Year exceed the maximum contribution permitted under
Code §415(c).
The following may be converted under the Plan.(select one or both)
I I Sick leave
2 I I Vacation leave
Eligible Employees.Only the following Participants shall receive the Employer contribution for sick leave andlor
vacation leave (select 3.and/or 4:leave blank if no limitations provided,however,that this Plan may not be used to
only provide benefits (or ierminated Employees)
3.(J Former Employees.All Employees terminating service with the Employer during the Plan Year and who
have satisfied the eligibility requirements based on the terms of the Employer’s accumulated benefits plans
checked below (select all that apply:leave blank if no exclusions):
a.I I The Former Employee must be at least age (e.g.,55)
b.(J The value of the sick and or vacation leave must be at least $(e.g..52.000)
c.I I A contribution “ill only be made if the total hours is over (e g..10)hours
d.I I A contribution will not be made for hours in excess of (c.g .40)hours
4.1 )Active Employees.Aciivc Employees who have not terminated service during the Plan Year and who meet
the following requirements (select all that apply:leave blank if no exclusions):
a.I I The Employee must be at least age (e.g..55)
b.I I The value of the sick and/or vacation leave must be at least $.............(e.g..52.000)
c.I I A contribution will only be made if the total hours is over (e.g..10)hours
d.I ]A contribution will not be made for hours in excess of_(e.g..40)hours
e.I J Social Security Replacement Plan.Except as provided below,the Employer will contribute an amount equal to 7.5%
of each eligible Participants Compensation for the entire Plan Year.reduced by mandatory Employee contributions that
are picked-up under Code §414(h)and Employer contributions to this Plan actually contributed io the Participant’s
Account during such Plan Year.(may only be selected if Question II b I.has also been selected)
AND,only the following Employees will NOT be eligible for the Social Security Replacement Plan contribution
(select all thai apply)
I J Pan-time Employees who are not otherwise covered by another qualit3ing public retirement system as
defined for purposes of Regulation §31 3121 (bX7)-2 A pan-time Employee is an Employee whose regularly
scheduled service is less than —Hours olService in the relevant eligibility computation period (as
defined in Plan Section 155).
2 (j Seasonal Employees who are not otherwise covered by another qualifying public retirement system as
defined for purposes of Regulaiion §31 312 l(bX7)-2 A seasonal Employee is an Employee who is
categorized as a seasonal Employee on ihe Employer’s payroll records
3.(j Temporary Employees wiio are not otherwise covered by another qualifying public retirement system as
defined for purposes of Regulation §31 .3l21(bX7)-2.A temporary Employee is an Employee who is
categorized as a temporary Employee on the Employer’s payroll records
4 (}Employees in elective positions (filled by an election,which may be by legislalive body,board or committee.
or by ajurisdictio&s qualified electorate)
5 (Other:_____________________________(any other group of Employees that is definitely determinable and
not eligible for the Social Security Replacement Plan contribution)
The minimum contribution of 7 5%stated above will be satisfied b>
a.(I the Employee only (specify the contribution at the mandatory Employee contributions Question 30)
b.(I the Employer only’
c.[both the Employee and the Employer.The Employee shaLl contribute the amount specified in
Question 30 for mandatory Employee contributions)and the Employer shall contribute 0oof
each eligible Participant’s Compensation.
NOTE:If a.ore above is selected,then the mandatory Employee contribution must be picked-up by the
Employer at Question 30 Also.if b.or c.above is selected,then the allocation conditions in Question 25
2020 Nationwide Financial Services,Inc.or its suppliers
10
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go.ernmental 401(a)
(I Fixed -tiered.The Employer will make matching contributions equal to a uniform percentage of each tier of each
Participant’s “matched Employee contributions”.deiermrned as follows
NOTE:Fill in onl>percentages or dollar amounts,but not both Irpercentages are used.each tier represents the
amount of the Participant’s applicable contributions that equals the specified percentage olthe Participant’s
Compensation (add additional tiers ilnecessary)
Tiers of Contributions Matching Percentage
(indicate $01%)
First %
Next ____%
Nest
Next
s I )Fixed ~ears of Senice.The Employer will make matching contributions equal to a uniform percentage ofeach
Participant’s “matched Employee contributions”based on the Participant’s Years of Service (or Periods of Sen ice it’the
elapsed time method is selected),determined as follo~’s (add additional tiers ilnecessar>)
Years (or Periods)of Service Matching Percentage
00
For purposes of thc above matching contribution formula,a Year (or Period)of Service means a Year (or Period)of
Service for:
I.I J vesting purposes
2.I J eligibility purposes
h [J Flexible Discretiona~Match.(may not be elected if this Plan is a Mone>Purchase Pension Plan)“Flexible
Discretionary Match”means a Matching Contribution i~hich the Employer in its sole discretion elects to make to the
Plan Except as specified belo~.,the Employer retains discretion over the formula or formulas for altocating the
Flexible Discretionor)Match,including the Discretionary Matching Contrtbution rate or amount,the limit(s)on
Elective Deferrals or Employee Contributions subject to match,the per Participant match allocation limit(s),the
Participants or categories of Participants who “ill receive the allocation,and the time period applicable to an>
matching formula(s)(collectively,the “Flesible Discretiona’)Matching Formula”).except as the Employer otherwise
elects in its Adoption Agreement,Such contributions will be subjeci to the Instructions and Notice requirement of
Section 4.12,reproduced below,unless the Employer elects to use a “Rigid Discretionary Match”in Election 26.R,h.t.
below.
The discretionary matching contribution under this Question 26 B.h is a “Flexible Discretionary Match”unless the
Employer elects to use a “Rigid Discretionary Match “(Choose I if applicable
I.[Rigid Discretionary Match.A “Rigid Discretionary Match”means a Matching Contribution which the
Employer in its sole discretion elects to make to the Plan.Such discretion will only pertain to the amount of
the annual contribution.The Employer must select the allocation method for this Contribution by selecting
among those Adoption Agreement options which confer no Employer Discretion regarding the allocaiion of
such discretionary amount.for example,the limit(s)on Elective Deferrals or Employee Contributions subject
to match,the per Participant match allocation limit(s),the Participants who will receive the allocation,and
the time period applicable to any matching formula(s).This “Rigid Discretionary Match”is not subject to the
Instructions and Notice requirement of Section 4 12
Section 4.12 provides:INSTRUCTIONS TO ADMINISTRATOR AND NOTIFICATION TO
PARTICIPANTS.For Plan Years beginning after the end of the Plan Year in which this document is first
adopted,if a “Flexible Discretionary Match’contribution fonnula 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 “Flexible Discretionary Match”to the Plan,the Employer must provide the Plan
Administrator or Trustee written instructions describing (I)how the “Flexible Discretionary Match’formula
will he allocated to Participants (e.g.,a uniform percentage of Elective Deferrals or a flat dollar amount).(2)
the computation period(s)to which the “Flexible Discretionary Match”formula applies,and (3)if applicable,
a description of each business location or business classification subject to separate “Flexible Discretionary
Match”allocation fonnulas.Such instructions must be provided no later than the date on which the “Flexible
Discretionary Match’is made to the Plan.A summary of these instructions must be communicated to
Participants who receive an allocation of the ‘Flexible Discretionary Match’no later than 60 days following
the date on wbich the last “Flexible Discretionary Match”contribution is made to the Plan for the Plan Year.
[J Discrciioaary -tiered.(may nat be elected if this Plan is a Money Purchase Pension Plan)The Employer may make
matching contributions equal to a discretionary percentage of a Participant’s “matched Employee contributions,”to be
determined by the Employer,of each tier,to be determined by the Employer Such discretion ~viII only pertain 10 the
2020 Nationwide Financial Sen ices,Inc or its supplters
12
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
~Vaiver of conditions for Participants NOT employed on the last day of the Plan jear.If b.l..2..3..or 5 is selected.
Participants who are not employed on the last day of the Plan Year in which one of the following events occur will be eligible to
share in the allocations regardless of the above conditions (select all that apply:leave blank ilnone apply)
c.I J Death
d.I J Total and Permanent Disability
e.I I Termination of employment on or after Normal Retirement Age
I (or Early Retirement Date
Conditions based on period other than Plan lear.The allocation conditions above will be applied based on the Plan Year
unless othenvise selected below.liselected.the above provisions ~ill be applied by substituting the term Plan Year ~~ith the
specified period (e g if Plan Year quarter is selected belo’.and the allocation condition is 250 flours of Service per quarter
cuter 250 hours (not 1000)at b.8.above)
I.I 1 The Plan Year quarter.
g.I I Payroll period.
h.[Other:___________(must be definitely determinable and not subject to Employer discretion and may not be longer than
a twelve month period).
29 FORFEITURES (Plan Sections 1.21 and 4.3(e))
Timing of Forfeitures.Except as provided in Plan Section I 21.a Forfeiture will occur:
a I I N A (may only be selected if all contributions art fully Vested (default provisions at Plan Section 4.3(e)apply))
b.(XI As of the earlier of(I)the last day of the Plan Year in which the former Participant incurs five (5)consecutive I-Year
Breaks in Service,or (2)the distribution olthe entire Vested portion olthe Participant’s Account,
c [As of the last day of the Plan Year in which the former Participant incurs five (5)consecutive I-Year Breaks in Service.
d.(I As soon as reasonably practical after the date the Participant severs employment.
Use of Forfeitures.(skip if this is NOT a Money Purchase Pension Plan:for Profit Sharing Plans rorfettures are disposed olin
accordance with Employer direction that is consistent with Section 1 3(e))
Forfeitures will be (select one):
e.I added to the Employer contribution and allocated in the same manner
1.IXI used to reduce any Employer contribution
g.I J allocated to all Participants eligible to share in the allocations of Employer contributions or Forfeitures in the same
proportion that each Participant’s Compensation for the Plan Year bears to the Compen atton olall Participants for
such year
h j other (describe the treatment of Forfeitures in a manner that is definitely
dctenninable and that is not subject to Lmployer discretion)
30 MANDATORY EMPLOYEE CONTRIBU1 IONS (Plan Sectton 48)(skip if mandatory Employee contributions NOT selected
at Question II .d)
Type oFniandato~Employee Contribution.The mandatory Employee contribution is being made in accordance with the
following.(select one)
a (I The mandatory Employee contribution is a condition of employment.
b I I The Employee must make,on or before first being eligible to participate under any Plan of the Employer,an
irrevocable election to contribute the mandatory Employee contribution to the Plan.No Eligible Employee will become
a Participant unless the Employee makes such an irrevocable election
~mount of mandatory Employee Contribution (select one)
c I I An Eligible Employee must contribute to the Plan %(not to e’cceed 25%)of Compensation.
d j An Ehgible Employee must,prior to his or her first Entry Date,make a one-time irrevocable election to contribute to
the Plan from %(not less than 1%)to %(not to exceed 25%)of Compensation.
Conditions of Ilandatory Employee Contributions
e I I Additional provisions and conditions:____________________________________________________(must be definitely
determinable.e.g..Only full-time Employees must make mandatory Employee contributions)
Employer pick-up contribution.The mandatory Employee contribution is “picked-up’by the Employer under Code §4 14(h)(2)
unless elected below (select if applicable)
f.I 1 The mandatory Employee contribution is not “picked-upS by the Employer.
DISTRIBUTIONS
3t FORM OF DISTRIBUTIONS (Plan Sections 6.5 and 6.6)
Distributions under the Plan may be made in (select all that apply:must select at least one)
a (XI lump-sums
b (XJ substantially equal installments
2020 Nationwide Financial Sen ices.Inc or its suppliers
14
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go’erninental 401(a)
i.I I Distributions may be made as soon as administrativeLy l’easible after the last day of the Plan Year coincident “ith or
next following severance of employment.
k.[Other _____________________________________(musi be objective conditions which are ascertainable and may not
exceed the limits of Code §40l(aX14)as set forth in Plan Section 6.7)
C.Timing after initial distributable neat.If a disiribution is not made in accordance with the above provisions upon (he
occurrence of the distributable event,then a Participant may elect a subsequent distribution at any time after the lime the amount
Was first distributable (assuming the amount is still distributable),unless otherwise selected below (may not be selected with 321.
and 32k):
I I Other:______________________________________(e.g..a subsequeni distribution request may only be made in
accordance with I abo~e U e,the last day of another Plan Year):must be objeciive conditions which are ascertainable
and may not exceed the limits olCode §40l(aXl4)as set forth in Plan Section 6.7)
I).Participant consent (I.e.,involuntary cash-outs).Should Vested Account balances less than a certain dollar threshold be
automatically distributed without Participant consent (mandatory distributions)?
NOTE:The Plan provides that distributions of amounts of 55.000 or less we only paid as lump’sums
m.I J No.Participant consent is required for all distributions.
n.[XI Yes,Participant conseni is required only if the distribution is over.
I.[J $5,000
2 [XI 51.000
3.[j $______(less than 51.000)
NOTE:If 2.or 3.is selected.rollovers will be included in detenmntng the threshold for Partictpant consent
Automatic IRA rollover.With respect to mandatory distributions of amounts that are 51.000 or less,if a Participant
makes no election,the amount will be distributed as a lump-sum unless selected below
4.If a Participant makes no election,then the amount will be automatically rolled over to an IRA provided the
amount is at least $(e.g..$200).
F,.Rotlovers in determination of $5,000 threshold.Unless otherwise elected belo”amounts atinbutable to rollover contributions
(if any)will be included in determining the $5,000 threshold for timing of distributions.fonn of dtstributtons.or consent rules.
o.Exclude rollovers (rollover contributions will be excluded in determining the 55.000 lhreshold)
NOTE:Regardless of the above election.tf the Participant consent threshold is $1 .000 or less.then the Administrator must
include amounts attributable to rollovers for such purpose.In such case,an election to exclude rollovers above will
apply for purposes of the timing and form of distributions.
33.DISTRIBUTIONS PON DEATH (Plan Section 6 8(b)(2))
Distributions upon the death of a Participant prior lo the “required beginning date”~vtll.
a [XI be made pursuant to the election of the Participant or “designated Beneficiary”
b I I begin within I year of death for a “designated Benefictary”and be payable over the ltfe (or over a period not exceeding
the “life expectancy”)of such Beneficiary.except thai if the “designated Beneficiary”is the Participant’s Spouse,begin
prtor to December 31st of the year in which the Participant ~ouId have attained age 70 1/2
c [be made ~~tthin 5 (or tf lesser )years of death for all Beneficiaries
d [be made within 5 (or if lesser )years of death for all Beneficiaries,except that if the “designated Beneficiary”is
the Participant’s Spouse.begin prior to December 31st of the year in which the Participant would have attained age
70 1/2 and be payable over the life (or over a period not exceeding the “life expectancy”)of such “surviving Spouse”
NOTE:The elections above must be coordinated wiih the Form of distributions (e.g..if the Plan only permits lump-sum
distributions,then options a.b.and d would not be applicable).
34 OTHER PERMITTED DISTRIBUTIONS (select all that apply;leave blank if none apply)
A IN-SERVICE DISTRIBUTIONS (Plan Section 6,11)
In-service distributions will NOT be allowed (except as otherwise permitted under the Plan without regard to this provision)
unless selected below (if applicable.ans~ser a.‘e.;leave blank if not applicable)’
a.IXI In-service distributions may be made to a Participant who has not separated from service provided the foIIo~~ing has
been sattsfied (select one or more)(options 2 5 may only be selected with Profit Sharing Plans).
I IX)Age The Participant has reached.(select one)
a [I Normal Retirement Age
b,j I ageó2
c.[)age 59 1/2 (may not be selected if a Money Purchase Pension Plan)
d.[Xi age 70 112 (may not be less than age 62 for Money Purchase Pension Plans)
2 [j the Participant has been a Participant in the Plan for at least years (may not be less than five (5))
3.[the amounts being distributed have accumulated in the Plan for at least 2 years
4 I I other:(must satisfy the definitely determinable requirement
under Regulations §401.1(b).may not be subject to Employer discretion.and must be limited to a
combination of items a I a 3 or a Participant’s disability))
2020 Nationwide Financial Services.Inc.or its suppliers
16
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go~ernmental 401(a)
~IISCELLANEOI.S
35.LOANS TO PARTICIPANTS (Plan Section 74)
a.[I New loans are NOT permitted.
b.[XI New loans art permitted.
NOTE:Regardless of whether rten loans are permitted.if the Plan pennits rollovers and/or plan-to-plan transfers,then the
Admtnisirator may.in a uniform manner,accept rollovers and/or plan-to-plan transfers of loans into this Plan
36 ROLLOVERS (Plan Section 4.6)(skip if rollover contributions are NOT selected at 11.1.)
Eligibility.Rollovers may be accepted from all Participants who are Employees as well as the l’ollo~’ing
(select all that apply:leave blank if not applicable).
a.IX)Any Eligible Employee,even prior to meeting eligibiltty conditions to be a Panicipani
b.I j Participants who are Former Employees
Distributions.When may distributions be made from a Participant’s Rollover Account9
c.[Xl At any lime
d.(J Only when the Participant is otherwise entiiled to an)dtstrtbution under the Plan
HEART ACT (Plan Section 4 II)(select one or more)
a.[HEART ACT Continued benefit accruals.Continued benefit accruals ~‘LlI apply
b [Distributions for deemed se’crance of employment.The Plan permit distributions for deemed severance of
employ mat.
2020 Nationwide Financial Services.Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
APPENDIX A
SPECIAL EFFECTIVE DATES AND OTHER PERMITtED ELECTIONS
A.Special effective dales (leave blank if not applicable):
a.I Special effective date(s):_________________________________________.For periods prior to the specified special
effective date(s).ihe Plan terms in effect prior to its restatement under this Adoption Agreement will control for
purposes of the designated provisions.A special effective date may not result in the delay ala Plan provision beyond
the permissible effective dale under any applicable law.(The Emptoyer has reliance on the IRS Opinion lAtter only if
the features described in the preceding sentence constitute protected benefits within the meaning of Code Section
41 I(d)(6)and the regulations thereunder,and only ilsuch features are permissible in a “Cycle 3”preapproved plan.i.e..
the features are not specifically prohibited by Revenue Procedure 2017-41 (or any superseding guidance)
B Other permitted elections (the following elections are optional):
a.[J Na other permitted elections
The follin,ing elections apply (select one or more):
b.(I Deemed 125 compensation (Man Section I 23).Deemed 125 compensation will be included in Compensation and 415
Compensation.
(XI Break-in-Service Rules The following Break-in-Service rules apply to the Plan.(select I.or 2.)
I.(XJ Reemployed after five(S)I-i ear Breaks in Service (“rule of parity”provisions)(Plan Section 3,5(e)).
The “rule olparity”pro’isions in Plan Section 3.5(d)“ill apply for (select one or both):
a.j eligibility purposes
b I I vesting purposes
2.I I Break-in-Service rules for rehired Employees.The foltowing Break-in-Service rules set forth in Plan
Sections 3.2 and 3 5 apply’(select one or both)
a all Break-in-Service rules set forth in such Sections.
b )only the follo~ving ____________________________(specify which provisions apply to the Plan)
d.IX)Beneficiary if no beneflcia~elected by Participant (Plan Section 6.2(0).In the event no valid designation of
Beneficiary exists.then in lieu of the order set forth in Plan Section 6.2(0.the following order of priority will be used.
Ii Survivinc Snouse 2.)Participant’s Estate.?Beneficiary?means the nenon (orentityl to whom all nra portion of a
deceased Participant’s interest in the Plan is payable.subtcct to the restrictions of Sections 6.2 and 6.6.t non death,the
Paflicioam?s survivina sDogSc is the Beneflciar~unless he or she consents to the Parltcipant?s naming another
Beneficia (specify an order of beneficiaries.e g -children per stirpes.parents.and then step-children)
e Joint and Survivor Annuity IPre-Retirensent Sun hor ~nnuity lithe Plan applies the Joint and Survivor Annuity
rules.then the normal form of annuity ~vilI be a joint and 50°4 sun ivor annuity (i e.ii 31 i or 31 j is selected)and the
Pre-Retirement Sur~ivor Annuity ‘vi I be equal to 50°of a Portictpant’s interest in the Plan unless selected bcIo~~
(select I.and/or 2.)
\ormal form olannuity.Instead ofajoint and 50%survivor annuity,the normal form of the qualified Joint
and Survivor Annuity will be:(select one)
a.j joint and 100%survivor annuity
b )joint and 75%sur~ivor annuity
c I )joint and 662(3%survt’or annuity
2 I I Pre-Retirenient Survivor Annuity.The Pre-Retirement Survivor Annuity (minimum Spouse’s death
benefit)will be equal to 50%of a ParticipanCs interest in the Plan unless a different percentage is selected
below’(select one)
a.[]100%of a Participant’s interest In the Man
b.L J %(may not be less ihan 50%)of a Participant’s interest in the Plan
Limitation scar (Plan Section 130)The Limitation Year for Code §415 purposes will be ____________(must be
a consecutive twelve month period)instead of the determination period”for Compensation.
g.I I 415 Limits when 2 defined contribution plans are maintained (Plan Section 4,4).If any Partictpant is covered under
another qualified defined contribution plan maintained by the Employer or an Affiliated Employer,or if the Employer
or an Affiliated Employer maintains a welfare benefit fund,as defined in Code §41 9(e)or an indivtdual medical
account,as defined in Code §41 5(lX2),under ‘,hich amounts are treated as “annual additions”with respect to any
Participant in this Plan,then the provisions of Plan Section 4.4(b)will apply unless othenvise specified below’
I.I I Specify,in a manner that precludes Employer discretion,the method under which the plans will limit total
“annual additions”to the “maximum permissible amount’and will properly reduce any “excess amounts”:
It.)Recognition of Service with other employers (Plan Sections I 40 and 1.55).Service with the follo~~ing employers (in
addition to those specified at Question IS)“ill be recognized as follows (select one or more):
2020 Nationnide Financial Services,Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
k I Other spousal provisions (select one or more)
I j )Definition of Spouse.The term Spouse includes a spouse under federal law as well as the following
2 j J Automalk revocation o(spousal designation (Plan Section 6.2(g)).The automatic revocation of a spousal
Beneficiary designation in the case of divorce does not apply.
3 1 I Timing of QDRO payment.A distribution to an Alternate Payee shall not be permitted prior to the time a
Participant would be entitled to a distribution.
Applicable la~i.Instead of using the applicable laws set forth in Plan Section 9.4(a).the Plan will be governed by the
la’~s or:_____________________________________________________________________
m IXI Total and Permanent Disability.Instead of the definition at Plan Section 1.50.Total and Permanent Disability means
A physical or mental impairment which is of such permanence and decree that.as determined b~the Employer,a
participant is unable because of such impairnwnt to perfonn pin substantial catnful activity for which he/she is suited
by virtue of hts4ter experience.trainine.or education and that has lasied.or can be exoected to last.for a continuous
period of not less than twelve (121 months,or can be expected to result in death.The permanence and decree of such
impairment shall be supported by medical evidence.If the Employer maintains a lone-term disability plan,the
definition of Total and Permanent Disability shall he the same as the definition of disability in the lone-term disability
uk!L (must be definitely determinable)
n I I Inclusion of Reclassiried Employees (Plan Section 1.17(a)).The Employer does not exclude Reclassified Employees
subject to the following provisions:(leave blank itnot applicable):
o I Claims procedures (Plan Section 210).The claims procedures forth in Plan Section 2.10(a)(b)apply unless
otherwise elected below or unless the Administrator has operationally adopted alternative procedures.
I [j The claims procedures set forth in Plan Section 2.10(c)(g)apply instead of Plan Section 2.10(a).
2 [The claims procedures set forth in Plan Section 2.l0(c)-(g)apply as follows:__________________________
(specify which provisions apply and/or modified)
p I J Age 62 In-Service Distributions For Tnnsferred Money Purchase Assets (Plan Section 6.11)
In-service distributions will be allowed for Participants at age 62.(applies only for Transfer Accounts from a Money
Purchase Pension Plan)(skip this question if the Plan is a Money Purchase Pension Plan or it in-service distributions
are already permttted for Transferred Accounts at Question 34)
Llmkations.The following limitations apply to these in-service distributions:
I.J The Plan already provides for in-service distributions and the restrictions set forth in the Plan (e.g..minimum
amount of distributions or frequency of distributions)are applicable to in-service distributions at age 62.
2 I J N A (no limitations)
3.J The following electtons apply to in-service distributions at age 62 (select one or more):
a.j J The minimum amount of a distribution is $(may not exceed $l.000).
b.I J No more than —distribution(s)may be made to a Participant during a Plan Year.
c.I ]Distributions may only be made from Accounts which are fully Vested
d.(J In-service dtstributions may be made subject to the following provisions (must be definitely
determinable and not subject 10 discretion).
q I I QIACs.(Plan Section 6 S(e)(4)A Participant may elect a QLAC (as defined tn Plan Section 6.8(eX4))or any
alternative form of annuity permitted pursuant to a QLAC in which the Participant s Account has been invested.
2020 Nation’.ide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
Use of Forfeitures
Forfeitures of Employer contributions other than matching contributions will be
c.I added to the Employer contribution and allocated in the same manner
d.(J used to reduce any Employer contribution
e.f J allocated to all Participants eligible to share in the allocations of Employer contributions or Forreitures in the same
proporlion that each Participants Compensation for the Plan Year bears to the Compensation of all Participants for such year
f.f J other:____________________________________(describe the treatment of Forfeitures in a manner that is definitely
determinable and not subject to Employer discretion)
Forfeitures of Employer matching contributions will be:
&J N A.Same as above or no Employer matching contributions.
h LXI used to reduce the Employer matching contribution
i.I I used to reduce an>Employer contribution
~.f other:____________________________________(describe the treatment of Forfeitures in a manner that is definitely
determinable and not subject to Employer discretion)
U.Directed inteatments
a.()Participant directed investments are NOT permitted.
b.IX]Participant directed investments are permitted from the following Participant Accounts:
I.(XJ all Accounts
2.l only from the following Accounts (select one or more)
a.(J Account attributable to Employer contributions
b.I I Rollover Account
c.I J Transfer Account
d.I ]Other:________________________________________(specify Account(s)and conditions in a manner that is
definitely determinable and not subject to Employer discretion)
E Rollover Limitations.Will the Plan accept rollover contributions and/or direct rollovers from the sources specified below?
a (]No.Administrator determines in operation which sources will be accepted.
b IXI Yes
Rollo~Cr sources.Indicate the sources of rollovers that will be accepted (select one or more)
I.IX]Direct Relievers.The Plan ‘sill accept a direct rollo”er of an eligible rollover distribution from (select one or
more):
a.I I a qualified plan described in Code §401(a)(including a 401(k)plan,profit sharing plan.defined benefit
plan.stock bonus plan and money purchase plan).excluding after-tax employee contributions
b.[X]a qualified plan described in Code §401(a)(including a 401(k)plan.profit sharing plan.defined benefit
plan.stock bonus plan and money purchase plan).including after-tax employee contributions
c.(I a plan described in Code §403(a)(an annuity plan).excluding after-tax employee contributions
d.[XI a plan described in Code §403(a)(an annuity plan).including after-tax employee contributions
e I I a plan described in Code §403(b)(a tax-sheltered annuity).excluding after-tax employee contributions
1.[X~a plan described in Code §403(b)(a tax-sheltered annuity).including after-tax employee contributions
g.IX)a plan described in Code §457(b)(eligible deferred compensation plan)
Direct Rolloven of Participant Loan.The Plan will NOT accept a direct rollover ala Participant loan from
another plan unless selected belou (leave blank if default applies)
h.I I The Plan will accept a direct rollover ola Participant loan
I I The Plan will only accept a direct rollover of a Participant loan only’in the following situation(s):
____________________________________________(e.g..only from Participants who were employees of
an acquired organization)
2.IX]Participant Rollover Contributions from Other Plans (i.e.,not via a direct plan-to-plan transfer).The Plan
will accept a contribution of an eligible rollover distribution (select one or more):
a (XI a qualified plan described in Code §401(a)(including a 401(k)plan.profit sharing plan.defined benefit
plan,stock bonus plan and money purchase plan)
b.{XI a plan described in Code §403(a)(an annuity plan)
c.[X]a plan described in Code §403(b)(a tax-sheltered annuity)
d.lxi a governmental plan described in Code §457(b)(eligible deferred compensation plan)
3.LXI Participant Rollower Contributions from lRAs:The Plan will accept a rollover contribution of the portion oI’a
distribution from a traditional IRA that is eligible to be rolled over and would otherwise be includible in gross
income.Rollovers from Roth IRAs or a Coverdell Education Savings Account (formerly known as an Education
IRA)are not permitted because they are not traditional IRAs.A rollover from a SIMPLE IRA is allo”td if the
amounts are rolled over after the individual has been in the SIMPLE IRA for at least two years.
F Trustee(s)or Insurer(s).Information regarding Trustee(s)/Insurer(s)(required for the Summary Plan Description and.if requested.
the Trust Agreement)
(Note:Select a.if not using provided trust.MUST select band following questions as applicable):
a.I I Do not produce the trust agreement
t 2020 Nationwide Financial Services.Inc.or its suppliers
2
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go.ernmeatal 401(a)
6.I I A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(ma>not be
selected with 3 or S
d.Name _______
Title/Email:
I.Title _______
2.Email ___________(optional)
Trustee is:(complete if g.selected above,select 3 6 as applicable)
3.(j Discretionary Trustee over all plan assets (ma>not be selected with 4 cr6
4.I A discretionary Trustee over the following plan assets (ma>not be selected with 3 cr5
5.I Nondiseretionar)Trustee over all plan assets ma not be selected with 3 4 cr6)
6.1 I A nondiscretionar>(directed)Trustee or Custodian over the following plan assets ________________(ma>
not be selected with 3.or S.)
e.Name __________
Title/Email:
I.Title _________
2.Email ___________(optional)
Trustee is:(complete if g.selected above,select 3 6 as applicable)
3.I I Discretionary Trustee over all plan assets (ma>not be selected with 4 or 6
4 [)A discretionary Trustee over the following plan assets (may not be selected with 3 or 5
5.1 )Nondiscretionaty Trustee over all plan assets (may not be selected with 3 4 or 6)
6.(J A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(may not be
selected with 3.or 5.)
f Name ________
Title/Email:
I Title ___________
2 Email (optionall
Trustee is:(complete if g.selected above,select 6.as applicable)
3.(J Discretionary Trustee over all plan assets (may not be selected with 4.or 6.)
4 1 I A discretionary Trustee over the following plan assets:___________(ma)not be selected with 3 orS
5 I I Nondiscretionaty Trustee over all plan assets (ma>not be selected with 3..4 or 6.)
6 I J A nondiscretionary (directed)Trustee or Custodian over the following plan assets (may not be
selected aith 3.or 5.)
g.Name
Title/Email:
I Title ___________
2.Email (optional)
Trustee is:(complete if g.selected above;select 3.6.as applicable)
3.[j Discretionary Trustee over all plan assets (may not be selected ~vith 4 or 6
4.[J A discretionary’Trustee over the following plan assets:___________(may not be selected with),or 5.)
5.I I Nondiscretionary Trustee over all plan assets (may not be selected with 3..4 or 6.)
6.I )A nondiscretionar>(directed)Trustee or Custodian over the follo~~ing plan assets ___________(ma)not be
selected with 3 or 5)
h.Name
Title/Email:
I.Title
2.Email (optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3.1 1 Discretionary Trustee over all plan assets (may nol be selected with 4.or 6.)
4.1 I A discretionary Trustee over the following plan assets:(may not be selected with 3.or 5.)
5.1 I Nondiscretionary Trustee over all plan assets (may not be selected with 3..4.or 6.)
6.[]A nondiscretionary (direcied)Trustee or Custodian over the following plan assets (ma>not be
selected with 3 or 5
i.Name
Title/Email:
I Title ________
2.Email ___________(optional)
Trustee is:(complete if g selected above:select 3.6.as applicable)
3 I )Discretionary Trustee over all plan assets (may not be selected with 4 or 6
4 I )A discretionary Trustee over the following plan assets’(may not be selected with 3 or 5
2020 Nationwide Financial Services.Inc or its suppliers
4
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go~ernmental 401(a)
Address/telephone numberlemail
I (J Use Employer address/telephone number entail
2 1 I Use following addre s/telephone number/email
a Street
b.Cii>
c Stale
d ZIP
e.Teleph
f Email
Investment in common,collective or pooled trust funds.The nondiscrelioriary Trustee,as directed or the discretionar>Trustee
acting without direction (and in addition to the discretionary Trustee’s authority to invest in its own funds).may invest in an>of
the following trust funds:(optional)
n I I (Specify the names of one or more trust hinds in “hich the Plan can invest)
Choice of law
o IX)This trust will be governed by the laws of the state of:
I (J State in which the Employer’s principal office is located
2 [XJ State in which the corporate trustee or insurer is located
3 (I Other ______________
2020 Nation”ide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 4O1(a)
ADOPTION AGREEMENT FOR
~ATIOMl IDE FINANCIAL SERVICES.INC.
NON-STANDARDIZED
GO’I ERN~IE!%TAL 401(a)PRE-APPROVED PLAN
CAL TION:Failure to properly fill out this Adoption Agreement may result in disqualification of the Plan.
EMPLOYER INFORMATION
(An amendntent to the Adoption Agreement is not needed solely to reflect a change in this Employer Information Section.)
EMPLOYERS NAME.ADDRESS.TELEPHONE NUMBER.TIN AND FIS AL YEAR
Name:City of Fort Collins
Address:300 LaPorte Avenue
Street
Fort Collins Colorado 8052!
City State Zip
Telephone:(9701 221-6535
Taxpayer Identification Number (TIN):84-6000587
Employer’s Fiscal Year ends:December 3 I
2.TYPE OF GOVI RNMFNTAL ENTITY.This Plan may only be adopted a state or local governmental entity.or agency thereof’.
including an Indian tribal government and may not be adopted by any other entity,including a federal government and any
agency or instrumentality thereof
a [I State government or state agency
b [j County or county agency
c (XJ Municipality or municipal agency
d.I Indian tribal government (see Note below)
NOTE:An Indian tribal govemmeni may only adopt this Plan if such entity is defined under Code ~770 I (a)(40).is a subdivision
alan Indian tribal government as determined in accordance with Code *7871(d).or is an agency or instrumentality ofeither,and
all of the Participants under this Plan employed by sucit entily substantially perform services as an Employee in essential
governmental functions and not in the performance of commercial acit’itics (whether or not an essential government function).
3.PARTICIPA1 INC EMPLOYLRS (Plan Section 139)Will any other Employers adopt this Plan as Participating Employers0
a.IXI No
b.L J Yes
MULTIPLE FMPLOYER PLAN (Plan Article Xl).Will any Employers who are not Affiliated Employers adopt Otis Plan as part
of a multiple employer plan (MEP)arrangement?
c [XI No
d [j Yes (Complete a Participation Agreement for each Participating Employer)
PLAN INFORMATION
(An amendment to the Adoption Agreement is not needed solely to reflect a change in the information in Question 9.)
4.PLAN NAME
Cit~of Fort Collins Police Plan
5.PLAN STATUS
a I I Net’Plan
b [XJ Amendment and restatement of existing Plan
C~CLE S RESTATEMENT (leave blank if not applicable)
I.[This is an amendment and restatement to bring a plan into compliance with the legislative and regulatory
changes set forth in IRS Notice 2017-37 (i e..the 6-year pit-approved plan restatement cycle)
6.EFFECTIVE DATE (Plan Section 1.16)(complete a.if nen plan:complete a AND b.if an amendment and restatement)
Initial Effective Date of Plan (except for restatements.cannot be earlier than the l5rsi day of the current Plan Year)
a.Januan I.2007 (enter month day,year)(hereinafter called the “Effective Date”unless 6 b is
entered below)
2020 Nation”ide rinancial Services.Inc or us suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
e.IXI After-tn voluntary Employee contributions
f [XI Rollover contributions (Question 36)
PRIOR CONTRIBUTIONS
The Plan used to permit,but no longer does,the folIo~ving contributions (choose all thai apply.if any)
~.1 ]Employer matching contributions
h.I I Employer contributions other than matching contributions
I I Rollover contributions
j.I After-tn voluntary Employee contributions
ELIGIBI LITi REQUIREME’VFS
12 ELIGIBLE EMPLOYEES (Plan Section 1.17)means oil Employees (including Leased Employees)EXCEPT those Employees
who are excluded bob”or elsewhere in the Plan:(select a.or bj
°.(I No excluded Employ en.There are no additional excluded Employees under the Plan (skip to Question 13).
b.IXI Exclusions.The follo”ing Employees are not Eligible Employees for Plan purposes (select one or more):
I.(I Union Employees (as defined in Plan Section 1.17)
2.j Nonresident aliens (as defined in Plan Section 1.17)
3.I I Leased Employees (Plan Section 1.29)
4.J Part-time Fmployecs.A part-time Employee is an Employee ~~hosc regularly scheduled service is less than
flours of Service in the relevant eligibility computation period (as defined in Plan Section 1.55).
5.[Temporary Fmployees.A temporary Employee is an tEniployce who is categorized as a temporary Employee
on the Fmployer’s payroll records.
6.[I Seasonal Employees A seasonal Employee is an Employee who is categorized as a seasonal Employee on
the Employer’s payroll records.
7.IXI Other:An Eligible [maloyec flit Plan Purposes shall mean any pcrson employed in the following Eligible
Groups:Sworn Police Officer (excluding ChietolPolice).Dispatcher.Dispatcher Supervisor and Dispatch
Manager (must be definitely determinable under Regulation §I 40 I -1(h).Exclusions may be employment
title specific but may not be by individual name)
NOTE:I foption 4.-6.(pail-time,temporary and/or seasonal exclusions)is selected,when any such excluded Employee
actually completes I Year of Service.then such Employee will no longer be part of this excluded class.For this
purpose.the I loon of Service method ~vili be used for the I Year ot’Service override regardless of any contrary
selection at Question I 6
13 CONDITIONS OF LLIGIBILITY (Plan Scction 3.1)
a.IXI No age and service required.No age and service required for all Contribution Types (skip 10 Question 14).
b.Eligibility.An fligible Fmployce “ill be eligible to participate in the Plan upon satisfaction of the follo~~ing (complete
c.and d select e and f ilapplicable)
Eligibility’Requirements
c.)Age Requirement
I [}No age requirement
2.[J Age2Ol/2
3.I )Age2l
4.I I Age (may not exceed 26)
d.I I Service Requirement
I.j No service requirement
2 I I (not to exceed 60)months of service (elapsed time)
3.j I Year olService
4 I ]_______(not to exceed 5)Years olService
5 I I consecutive month period from the Eligible Employees employment commencement date and during
which at least ________Flours of Service are completed.
6 [J consecutive months of employment.
7 [J Other:(e g.date on which 1.000 Hours of Service is
completed within the computation period)(must satisfy the Notes below)
NOTE:If c 4 or d 7.is selectcd.the condition must be an age or sen ice requirement that is definitely determinable and may
not e%ceed age 26 and may not exceed 5 Years of Service.
NOTE:Year of Service means Period of Service if the elapsed time method is chosen.
~~aiver of conditions.The service and/or age requirements specified above “ill be waived in accordance with the following
(leave blank if there are no waivers of conditions):
e.I I If employed on ______________the foil o’~tng requirements.and the entry date requirement.will be waived.The
waiver applies to any Eligible Employee unless 3.selected belo~~.Such Employees nill enler the Plan as of such date
(select I and/or 2.AND 3.if applicable):
I [J serlice requirement (may let pan-lime Eligible Employees into the Plan)
2020 Nation’sidc Financial Services.Inc or its suppliers
3
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go’eramental 401(a)
3.For eligibility purposes.the computation period will be as defined in Plan Section 1.55 (i.e..shifl to the Plan Year if
the eligibility condition is one (I)Year of Service or less).
4.For vesting,allocation,and distribution purposes.the computation period ~vilI be the Plan Year.
5.Upon an Employee’s rehire,all prior service with the Employer is taken into account for all purposes.
a.IX)Elapsed time method.(Period olService applies instead ofYearofScrvice)Instead of HoursofSenice.elapsed time
will be used for:
I.IX]all purposes (skip to Question Il)
2.1 ]the following purposes (select one or more):
a j eligibility to participate
b [J vesting
c.I I allocations,distributions and contributions
b.Alternative definitions for the Ilours of Senice method.Instead of the defaults,the following alternatives will apply
for the Flours of Service method (select one or more):
I.()Eligibility computation period.Instead oishitling to the Plan Year.the eligibility computation period afler
the initial eligibility computation period will he based on each anniversary of the date the Employee first
completes an Flour of Service
2.[Vesting computation period.Instead of the Plan Year.the vesting computation period will be the date an
Employee first performs an Flour of Service and each anniversary thereof.
3 I I Equivalency method.Instead of using actual Ilours of Service.an equivalency method will be used to
dctcrmine I-tours of Service for:
a.{all purposes
b.I the following purposes (select one or more):
I.I I eligibility to participate
2.)vesting
3.allocations,distribution and contributions
Such method will apply to:
c.all Employees
d.Employees for whom records niactual I lours of Sen ice are not maintained or available
(e.g..salaried Employees)
e.I I other:___________________________________________(e.g..per-diem I mployees only)
[tours of Service will he determined on the basis of:
C I )daysworked(l0hoursperday)
g.I I weeks worked (45 hours per week)
h.I semi-monthly payroll periods worked (95 hours per semi-monthly pay period)
I I months worked (190 hours per month)
bi-weckly pay rol periods worked (90 hours per hi-weekly pay period)
k.I I other;_______________________________________________(e.g..option f.is used for per-diem
Employees and option g.is used lbr on-call Employees).
4 (]Number of Hours of Service required.Instead of 1,000 hours of Service,Year of Service means the
applicable computation period during which an Employee has completed at least ______(not to e~cceed
1.000)Ilours of Service for
a.I I all purposes
b.I )the following purposes (select one or more).
I.I )eligibility to participate
2 I vesting
3.(j allocations,distributions and contributions
c.I I Alternati,e for counting all prior service.Instead of the default which recognizes all prior sen ice for rehired
Employees,the Plan will not recognize prior service and rehired Employee are treated as new hires for the following
purposes:(select one)
I.[)all purposes
2.[J the following purposes (select one or more):
a,I J eligibility to participate
b.I ]vesting
c j )sharing in allocations or contributions
C 2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Gas’ernmenial 401(a)
Years (or Periods)olScrvice Percentage
%
%
00
%
NOTE:If any Part-tinie(SeasonaV[emporary Employees “ho are not covered under Social Security are participating ‘it ibis
Plan as a Social Security Replacement Plan,any contributions used to satisfy the minimum contribution requirements
of Question 24.e will be 100°.vested
1$VESTING OPTIONS
Excluded sesling Sen ~Ct.The following Years olService “ill be disregarded for vesting purposes (select all that apply.leave
blank if none apply)
a.[j Service prior to the initial Eflèctne Dale ol’the Plan or a predecessor plan (as defined in Regulations ~I 41 l(a).5(b)(3))
b [J Service prior to ihc computation period in which an Employee has attained age ________
c.[I Service during a period (hr ‘vhich an Employee did not make mandator3 Employee contributions.
‘testing br death,Total jad Permanent Disability and Larlyfttormat Retirement.Regardless of the vesting schedule,a
Participant will become fully Vested upon (select all that apply.leave blank if none apply)’
d IX)Death
e (XJ Total and Permanent Disability
I I J Early Retirement Date
g IXI Normal Retirement Age
RETIREMLNT iCES
19 NORMAl RCTIREMEN1 AGE (“NRA”)(Plan Section I 33)means (9
ibis Question 19 and Question 20 may be skipped ifthe Plan does not base any benefits.distributions or other features on
Normal Retirement Age
a (XI Specific age.The date a Participant attains age S
b j J ~ge/participation.The later of the date a Participanl attains age or the _______anniversary of the first day of
the Plan Year in which participation in the Plan commenced
c.I I Other:______________________(musl be definitely deterimnable)
NOTE:If this is a Money Purchase Pension Plan and in’service distributions at Normal Retirement Age arc permitted,then the
Normal Retirement Age cannot he less than age 62.or age 50 if substantially all Participants are qualified public safety
employees (as defined in Code §72(i)(I))The “substantially all”requirement for qualified public safety employees ~.ill
no longer be a requirement as of the effective dale of tlte final regulations once they are issued &effectne.If an age
less than óhs inserted (unless the age 50 safe harbor is applicable for a qualified public safety employee),no reliance
will be afforded on the Opinion Letter issued to the Plan that such age is reasonably representative of the typical
retirement age for the industry in ~~hich the Participants works Effective for Employees hired during Plan Years
beginning on or after the later of(I)January I.2015,or (2)the close of the first legislative session of the legislative
body with the authority to amend the plan that begins on or after the date Ihat is three (3)months after the final
regulations are published in the Federal Register.an NRA of less than age 62 must comply with the final regulations
under §401(a).
Qualified public safety employees.Normal Retirement Age for public safety employees (as defined in Code §72(t)(I))(leave
blank ilnot applicable)
d [X~Age ,,,~j,,(may not be less than 50 for a Money Purchase Pension Plan or 40 for a Profit Sharing Plan)
20 NORMAL RETIREMENT DATE (Plan Section 134)means,with respect to any Participant,the
a (XI date on ~~hich the Participant attains “NRA”
b.I J first day of the month coinciding t’ith or next following the Participant’s “NRA”
c I )first day of the month nearest the Participani’s “NRA”
d.L )Anniversary Dale coinciding with or next follo~~ing the Participant’s “NRA”
e (J Anniversary Date nearesi the Participant’s “NRA”
f I I Other ________________(e g..first day of the month follo~’ing the Participaitt’s “NRA”).
2020 Nationaide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standairdized Governmental 401(a)
2 I )Regular pay will be excluded
3 [J Leave cash-outs will be excluded
3.[X)Nonqualified unfunded deferred compensation will be excluded
5.[Military Differential Pa>will be included
6 I 1 Disability continuation payments will be included for all Participants and the salary continuation will continue
for the following (iced or determinable period
e.(J Other:____________________(must be definitely determinable)
CON1 RlBL TIONS AND ALLOC ~TlO’%S
24 EMPLOYER CONTRIB rtONS (OTIILR 1 hAN MATCHING CON I RIB TIONS)(Plan Section 4.l(b)(3~)(skip to Question
26 if Employer contributions are NOT selected at Question II .b.)
CONTRIBUTION FORMULA (select one or more of the t’ollowing contribution formulas:)
a.I I Discretionary contribution (no groups).(may not be elected if this Plan is a Money Purchase Pension Plan)The
Employer may make a discretionary contribution,to be determined by the Employer.Any such contribuiion will be
allocated to each Participant eligible to share in allocations in the same ratio as each Participant’s Compensation bears
to the total of such Compensation of all Participants
b I I Discretionary contribution (Grouping method).(may not be elected if this Plan isa Money Purchase Pension Plan)
The Employer may designate a discretionary contribution to be made on behalf of each Participant group selected
below (only select I or 2 )The groups must be clearly defined in a manner that “ill not violate the definite
predetermined allocation lbnnula requirement ot’Regulation §1.401 -l(b)(I )(ii).The Employer must notify the 1 rustee
in writing of the amount of the Employer Coniribution being given to cach group.
I I I Each Participant constitutes a separate classification.
2 [I Participants will be divided into the following classifications with the allocation methods indicated under
each classification.
Definition of classifications.Define each classification and specify the method of allocuting the contribution
among members of each classtfication.Classifications specified below must be clearly defined iTi a ntanner
that will not violate the definitely detemiinahle allocation requtrenient of Regulation I 401-I (bX I Xii).
Classilication A will consist of
The allocation method will be I I pro rata based on Compensation
I I equal dollar amounts (per capita)
Classification B will consist ol’_______________________________________________
The allocation method will be:I I pro rata based on Compensation
I I equal dollar amounts (per capita)
Classification C “ill consist of___________________________________________
‘[he allocation method will be:T I pro rata based on Compensation
I J equal dollar amounts (per capita)
Classification D will constst of _______________________________________________
The allocation method will be.j )pro rata based on Compensation
I equal dollar amounts (per capita)
Additional Classifications ________________________________________(specify the classifications and which
of the above allocation methods (pro rata or per capita)will be used for each classification).
NOTE:If more than four (4)classifications,the additional classifications and allocation methods may be
attached as an addendum to the Adoption Agreement or may be entered under Additional
Classifications above
Deterinittatlon of applicable group.ha Participant shifts from one classification to another during a Plan
Year then unless selected below,the Participant is in a classification based on the Participants status as of
the last day of the Plan Year.or if earlier.the date of termination ofemployrnent.If selected below,the
Admtni trator will apportion the Participants allocation during a Plan Year based on the following.
a (Beginning of Plan Year.The classification will be based on the Participant’s status as of the
beginntng of the Plan Year
b I I Months in each classification Pro rata based on the number of months the Participant spent in each
classification
c I I Days in each classification Pro rata based on the number of days the Participant spent in each
classification.
d [J One classification only’.The Employer will direct the Administrator to place the Participant in only
one classification for the entire Plan Year during ~vhich the shill occurs.
c IX)Fixed contribution equal to (only select one).
I [J %of each Participant’s Compensation for each
a.I I Plan Year
b )calendar quarter
c.J month
2020 Nationwide Financial Sen ices.Inc.or its suppliers
9
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
NOTE:I Ia.ore.above is selected then the mandatory Employee contribution must be picked-op by the
Employer at Question 30.Also,jib,ore,above is selected,then the allocation conditions in Question 25
below do not apply to the Employer contribution made pursuant to this provision.
f.(j Other:____________________________(the formula described must satisfy the definitely determinable requirement
under Regulation ~1.401 -1(b)and if this is a Money Purchase Pension,it must not be a discretionary contribution
formula).NOTE:Under Question 24.1..the Employer may only describe the allocation of Nonelective Contributions
from the elections available under Question 24 and/or a combination thereof as to a Participant gmup or contribution
type (e.g..pro rata allocation applies to Group A contributions to other Employees will be allocated in accordance with
the classifications allocation provisions oIPlan Section 43 with each Participant constituting a separate classification)
25 ALLOCATION CONDITIONS (Plan Section 4.3).If 24.a..b..c..or f is selected above,indicate mquiremcnts to share in
allocations of Employer contributions (select a.OR b.and all that apply at c.-e.)
a.IXI No conditions.All Participants share in the allocations regardless of senice completed during the Plan Year or
employment status on the last day of the Plan Year (skip to Question 26)
b Allocation conditions apply (select one of I.-5.AND one of 6.9.below)
Conditions for Participants NOT employed on the last day of the Plan Year
I I I A Participant must complete at least __________(not to exceed 500)Ilours of Service if the actual
hours/equivalency method is selected (or at least (not to exceed 3)monthsolsenice if the elapsed
time method is selected).
2.I I A Participant must complete a Year of Service (or Period oiServicc if the elapsed time method is selected).
3.j I Participants will NOT share in thc allocations,regardless oI’ser~ice.
4.Participants will share in the allocations,regardless of scrvtcc.
5.I I Other:___________________________(must be definitely determinable and not subject to Employer
discretion)
Conditions for Participants employed on the last day of the Plan Scar
6.I No service requirement.
7.I A Participant must complete a Year of Sen ice (or Period olService if’the elapsed time method is selected)
8.I I A Participant must complete at least ______I lours of Service during the Plan Year.
9.I I Other:______________________________(must be definitely determinable and not subject to I niployer
discretion)
Waiver of conditions for Participants NOl’employed on the last day of the Plan l’ear.llb.I..2..3..or 5.above is selected.
Participants who are not employed on the last day of the Plan Year in which one oIthe following events occur will be eligible to
share in the allocations regardless olthe above conditions (select all that apply:leave blank if none apply)’
c.I I Death
d.J Total and Permanent Disability
e.j Termtnation of employment on or after Normal Retirement Age
I.J or Early Retirement Date
26,EMPLOYER MATCHING CON1’RIBUTIONS (Plan Section 4.l(b)(2)and Plan Section 4.12).(skipto Question 29 ifmatching
contributions are NOT selected at Question I Ic.)The Employer will (or may with respect to any discretionary contribution)
make the following matching contributions:
A Employee contributions taken into account.For purposes of applying the matching contribution provisions below,the
following amounts are being matched (hereafter referred to as “matched Employee contributions”(select one or morc)
a I J Llective deferrals to a 457 plan.Enter Plan name(s):_______________________
b I I Elective deferrals to a 403(b)plan.Enter Plan name(s):
c I Voluntary Entployee Contributions
d I I Other:____________________(specify amounts that are matched under this Plan and are provtded ror within this
Adoption Agreement)
B ~tatching Formula.(select one)
e.I J Fixed -uniform rate/amount.The Employer will make matching contributions equal to _%(e.g..50)of the
Parttcipant’s “matched Employee contributions”
I J that do not exceed ,..........,,%ofa Participant’s Compensation (leave blank if no limit)
Additional matching contribution (choose 2 ii applicable)’
2 [J plus an additional matching contribution of a discretionary percentage determined by the Employer.
a I I but not to exceed _%of Compensation.Such contribution is subject to the Instructions and
Notice requirement of Sectton 4.12
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Go~ernmental 401(a)
amount of the contribution.The tiers may be based on the rate of a Participant’s “matched Employee contributions”or
Years of Service.Such contribution is subject to the Instructions and Notice requirement of Section 4 12
NOTE:Fill in only percentages or dollar amounts.but not both.If percentages are used.each tier represents the amount
of the Participants applicable contributions that equals the specified percentage of the Participant’s Compensation (add
additional tiers if necessary):
Tiers of Contributions Matching Percentage
(indicate $or 0a)
First _______
00
Next ______°o
Next _______
~.{I Other:_________________________________________(the formula described must satisfy the definitely determinable
requirement under Regulation §1.401-1(b)and if this isa Money Purchase Pension Plan,it must not he a discretionary
contribution formula.NOTE:Under Question 26 8.j..the Employer ma)only describe the allocation of Matching
Contributions from the elections available under Question 26 and/or a combination tliereolas to a Participant group or
contribution type (e.g..fixed unifonu rate applies to Group A.contributions to other Employees will be allocated as a
tiered contribution.)
27.MATCI IlNO CONTRIBUTION PRO VISIONS
A.Maximum matching contribution.The total matching contribution nude on behaliof any Participant lbi any Plan Year will not
exceed:
a.[I N/A (no Plan specific limit on the amount of matching contribution)
h.II$___
I I ______%of Compensation
B Period of determination.Any matching contribution other titan a Flexible Discretionary Match”will be applied on the
following basis (and matched Employee contributions and an>Compensation or dollar lintitatton used in determining the
matching contribution ~~ill be based on the applicable period Skip if the only Matching Contribution is a rlexible Discretionary
Match,):
d.j the Plan Year (potential annual true-up required)
e.I I each payroll period (no true-up)
f.I I each month (potential monthly true-up required)
&}each Plan Year quarter (potential quarterly true-up required)
h I I each payroll unit (e.g..hour)(no true-up)
Other (specify)____________________________________1 he time period described must be definitely determinable
under 1 Icas Reg.§1.401-1(b).This line may be used to apply different options to different matching contributions
(e g.Discretionary matching contributions will be allocated on a Plan Year period uhile fixed matching contributions
“ill be allocated on each payroll period.)Such coturibution period is subject to the Instructions and Notice requirement
of Section 4.12.
28.Al LOCATION CONDITIONS (Plan Section 4.3)Select a.OR b.and all that apply of c.-h.
a.I I No conditions.All Participants share in the allocations regardless of service completed during the Plan Year or
employment status on the last day of the Plan Year (skip to Question 29)
b.Allocation condilions apply (select one oil.-5.AND one o16.-9.below)
Conditions for Participants NOT employed on the last day of the Plan lear.
I.I J A Participant must complete more than Hours of Service (or months of service if the elapsed
time method is selected).
2.I A Participant must complete a Year of Sen ice (or Period of Service if the elapsed time method is selected)
3.[J Participants will NOT share in the allocations,regardless of service.
4.I J Participants will share in the allocations,regardless of service,
5.I I Other:_____________________________________(must be definitely determinable)
Conditions for Participants employed on the Inst day oldie Plan lear
6.J No service requirement.
7.(j A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected),
8.[J A Participant must complele at least _______Flours of Service during the Plan Year.
9.(J Other:___________(must be definitely determinable and not subject to Employer discretion)
Ilaiter orconditlons for Participants NOT employed on the last day of the Plan lear.Iib.l..2..3..or5.is selected.
Participants who are not employed on the last day of the Plan Year in which one of the following events occur will be eligible to
share in the allocations regardless of the above conditions (select all that apply:lea’e blank if none apply)
c [Death
d.I )Total and Permanent Disability
e I I Termination of employment on or after Normal Retirement Age
I ]or Early Retirement Date
2020 Nationuide Financial Services.Inc.or its suppliers
t3
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
f.[X~other:Any other sequence as requested b~the Participant (must be definitely determinable and not subject to
Employer discretion)
NOTE:Regardless of the above,a Participant is not required to request a ~iithdrawaI of his or her total Account for an
in-service distribution,a hardship distribution,or a distribution from the Participant’s Rollover Account
Cash or property.Distributions may be made in
g.[J cash only.except for (select all that app!>:leate blank if none apply):
I.insurance Contracts
2.I J annuity Contracts
3.F I Participant loans
4 j all investments in an open brokerage ~vindot’or similar arrangemeni
h.IXI cash or property.except that the following limitation(s)apply:(leave blank il’there arc no limitation on propcrt~
distributions).
I [X)Tax-free distributions of up to 53.000 for the direct pa~ment ofotialifying insurance rwemiums for eligible
retired public safets officers are available under the Plan (must be definitely determinable and not
subject to Employer discretion)
Joint and Sunhor Annuity proiisions.(Plan Sections 6.5(e)and 6.6(e)(select one)The Joint and Sun’i~or Annuity pros i ions
do not apply to the Plan unless selected belo”(choose if applicable)
i.j Joint and Sunhor %nnuity applicable as normal form of distribution.The Joint and Sun ivur annuity rules set
forth in Plan Sections 6.5(e)and 6.5(0 apply to all Participants (if selected.tltcn annutttcs are a lorni of distribution
under the Plan e~1~n if e above is not selected)
j.I Joint and Sun’i.or Annuity ruin apply based on Participant election Plan Section 65(0 “ill apply and tltejoint
and survivor ailes orCode **40l(a)(.ll)and 417 (as set tinlh in Plan Sections 6.5(e)and 66(e)will apply only if an
annuity fomt of distribution is selected by a Participant
AND,if i.or).is selected abo~e.the one-year marriage rule does not apply unless selected below (choose if applicable)
I.F I The one-year marriage rule applies
Spousal consent requirements.Spousal consent is not required for any Plait provisions (except as otlienvicc elected in i above
for the joint and surviyor annuity rules)unless selected below (choose ifappheable)
k.j Required for all distributioas.A Spouse must consent io all distributions (other titan required minimum distributions)
I.F I Beneficiary designations.A married Participant’s Spouse will be the Beneficiary of the entire death benefit unless the
Spouse consents to an alternate Beneficiary.
AND,if k,or I.is selected,the one-year marriage rule does not apply unless selected below (choose ilapplicable).
I I The one-year marriage rule applies.
32 CONDITIONS ~OR DISTRIBUTIONS UPON SEVERANCE OF’EMPLOYMLN1 Distributions upon severance of
employment pursuant to Plan Section 6.4(a)will not be made unle~the following conditions have been satisfied-
A %ccounts in excess of $5,000
a IXI Distributions may be made as soon as administratively feasible following severance of employment.
b j Distributions may be made as soon as administratively feasible after the last day of the Plan Year coincident with or
next following severance of employment.
c )Distributions may be made as soon as administratively feasible after the last day of the Plan Year quarter coincident
with or next following severance ofemploynieni.
d {I Distributions may be made as soon as administratively feasible after the Valuation Dale coincident with or next
following severance ofemployment.
e I I Distributions may be made as soon as adniinislratively feasible after months have elapsed following severance
of employment
f L I No distributions may be made until a Participant has reached Early or Normal Retirement Date.
g I I Other _____________________________________(must be objective conditions which arc ascertainable and may not
exceed the limits of Code *401 (aX 14)as set forth in Plan Section 6.7)
B.Accounts of $5,000 or less
h [XJ Same as above
i.[Distributions may be made as soon as administratively feasible lbllowing severance of employment.
I Distributions may be made as soon as administratively feasible after the last day of the Plan Year coincident with or
next following severance of employment.
Ic.(Other (must be objective conditions which arc ascertainable and may not
exceed the lintits ofCode §40l(a)(,14)as set forth in Plan Section 67)
C Timing alter initial distributable event.If a distribution is not made in accordance with the above provisions upon the
occurrence of the distributable event,then a Participant may elect a subsequent distribution at any time after the time the amount
2020 Nationwide Financial Services.Inc or us suppliers
IS
EXHIBIT A TO RESOLUTION 2024-072
Son-Standardized Go~ernmen(al 401(a)
Account restrictions.In-sen ice distributions arc permitted front the following Participant Accounts
b.[j all Accounts
c.I I only from the following Accounts (select one or more):
I.J Account attributable 10 Employer matching contributions
2.]Account attributable to Employer contributions other than matching contributions
3.1 1 Rollover Account
4.(1 Transfer Account
Permitted from the following assets attributable to (select one or both)
a.(J non-pension assets
b )pension assets (e.g..from a Money Purchase Pension Plan)
5 I I Mandatory Employee Contribution Account
6.(I Other.
Limitations.The following limitations apply to in-service distributions
d IXI N A (no additional limitations)
e I I Additional limitations (select one or more)
I ()The minimum amount ofa distribution is $______
2 I I No more than distribution(s)may be made to a Participant during a Plan Year.
3.Distributions may only be made from Accounts “hich are fully Vesled.
4.J In-service distributions may be made subject to the follossing provisions:
determinable requirement under Regulation 1.401-1(b)and not be subject to Employer discretion).
B IIARDSI lip DISTRIBUTIONS (Plan Sections 6 12)(may not be selected iltlus is a Mont)’Purchase Pension Plan)
I Iardship distributions will NOT be allowed (except as otherwise permitted under the Plan without regard to this provision)
unless selected below (leave blank if not applicable)
I 1 I llardship distributions art permitted from the following Participant Accounts
I I I all Accounts
2.only from the Pollosvtng Account (select one or more):
a.I I Account attributable to Employer matching contributions
b.I I Account attributable to Employer contributions other titan matching contributions
c.I )Rollover Account (ilnot available at any time under Question 36)
d 1 ransfer Account (other than amounts attrthutable to a money purchase pension plan)
e (Mandatory Lmployee Contribution Account
I.(I Other
Additional limitations.The following limitations apply to hardship distributions:
3 I J N A (no additional Immitattons)
4.I I Addittonal limitations (select one or more):
a.(J The minimum amount of a distribution is $______
b.I I
dli
eli
Beneflcia~Hardship.Flardshmp distributions for Beneficiary expenses are NOT allowed unless otherwise selected
below
51)
and is not subject to Employer discretion)
(specify Account(s)and
conditions in a manner that satisfies the definitely determinable requirement under Regulation §1.401-1(b)
(must satisfy the definitely
(specify Account(s)and conditions in a manner
that m dcltmtely determinable and not subject to I mploycr discretion)
NOTE:I lardship distributions are NOT permitted from a Transfer Account attributable to pension assets (e g.front a
Money Purchase Pension Plan)
No more than distribution(s)may be made Lo a Participant during a Plan Year
Distributions may only be made from Accounts which are fully Vested.
A Participant does not include a Former Employee at the time of the hardship distribution
I lordship distributions may be made subject io the following pros isions.(niust satisfy the
definitely determinable requircment under Regulation §1.401-1(b)and not be subject to Employer
discretion).
Hardship distributions for espenses of Beneficiaries are allowed
Special effectise date (may be left blank if e(fective date is same as the Plan or Restatement EtIeeti’.e Dale
select a.and.if applicable b
a ()eftecttveasof
b.I I eliminated cflecti’e as of
4.2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
~on-SIandardized Go’ernmental 401(a)
keIi.ncc on Provider Opinion Letter.The Provider has obtained from the IRS an Opinion Letter specifying the lbrtn of this document
satisfies Code §401 as of the date of the Opinion Letter.An adopting Employer may rely on the Provider’s IRS Opinion Letter on,).to the
extent provided in Rev.Proc.2017-41 or subsequent guidance.The Employer may not rely on the Opinion Letter in certain other
circumstances or with respect to certain qualification requirements.‘~hich are specified in the Opinion Letter and in Rev.Proc.2017-41 or
subsequent guidance.In order to ha~•e reliance in such circumstances or with respect to such qualification requirements.the Employer must
apply for a determination letter to Employee Plans Determinations of the IRS.
An Employer who has ever maintained or ~~ho later adopts an mdi’idual medical account.as defined in Code *41 5t,l)(211 in addition to this
Plan may not rely on the opinion letter issued by the Internal Revenue Service with respect to the requirements of Code*4 I 5
This Adoption Agreement may be used only in conjunction with the basic Plan document #03.Ibis Adoption Agreement and the basic
Plan document “ill together be known as Nationwide Financial Senices.Inc.Non-Standardized Governmental 40 1(a)Pre-Approved Plan
#001.
The adoption of this Plan.its qualification by the IRS.and the related tax consequences are the responsibility of the Employer and its
independent tax and legal advisors.
Execution for Page Substitution imendment Only.lithis paragraph is completed,this Execution Page documents an amendment to
Adoption Agreement Election(s)________effective _____________.by substitute Adoption Agreement page number(s)________-The
Employer should retain all Adoption Agreement Execution Pages and amended pages.(Note The Effective Date ma,t’&retroactive or flint’
be prospective.)
The Provider.Nationwide Financial Services.Inc.will notify the I mployer of any amendment to this Pre-approved Plan or of any
abandonment or discontinuance by the Pro’ida of its maintenance of this Prc-appmvcd Plan.In addition,this Plan is provided to the
Employer either in connection with investment in a product or pursuant to a contract or other arrangement for products and/or services.
Upon cessation of such investment in a product or cessation of such contract or arrangement.as applicable,the Employer is no longer
considered to be an adopter of ihis Plan and Nationwide Financial Scn’ices.Inc.no longer has any obligations to the Employer that relate
to the adoption of this Plan.For inquiries regarding the adoption of the Pre-approved Plan.the Provider’s intended meaning ol’any Plan
provisions or the effect of the Opinion Letter issued to the Provider,please contact the Provider or the Provid&s representative.
Provider Name:Nationwide Retirement Solutions
Address P 13 x 182797
Ohio 43218
Telephone Number:877 4 -1630
Email address (optional):
The Employer,by executing belo~~,hereby adopts this Plan (add additional signature lines as needed).NOTE:If more than one Plan type is
adopted.the Plan Pro’ider must pro’ide multiple plan documents for Employer signature.
EMPLOYER City of Fort Collins
By
DATE SIGNED
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
Contribution
Eligibility Vesting Allocation
I I Employer name:a.1 J b.l I c I
2.I I Employer name:a.I b.(J c.j I
3.[Employer name:a.I )b.I I c.I I
4 [)Employername:all bil CII
5.I I Employer name:a.I I b.c.(I
6.(Employernamc:a.I I b.I J c.I I
Limitations
7.1 I The following provisions or limitations apply “ith respect to the a.I I b.I I c.
recognition of prior service:________________________________________
(e.g..credit service with X only on/following 1119)
I j Other testing provisions.The following vesting provisions apply to the Plan (select one or more):
I I I Special vesting provisions.The following special pros isions apply to the vesting provisions of the Plan:
____________________(must be delinitely determinable and satisfy the parameters set Ibrth al Question II)
2.I I Pre-amendmen vesting schedule.(Plan Seciion 6.4(b))If the vesting schedule has been amended and a
different vesting schedule other than the schedule at Question 17 applies to any Participants,then the
following provisions apply (must select one ala d.):
Applicable Participants.The vesting schedules in Question I?only apply to:
a.[j Participants who are Employees as of _____________________(enter date).
b Participants in the Plan who have an I lour of Service on or oiler _____________________(enter
date).
c.I I Participants (even if not an Employee)in the Plait on or afler (enter date).
d.I I Other:_________________________(e.g..Participants in division A Must be definitely
determinable.)
I I Minimum distribution transitional rules (Plan Section 6.8(e)(5))
NO’lE:‘Ibis Section does not apply to (I)a new Plan.(2)an amendment or restatement of an e~dsting Plan that ne’er
contained the provisions of Code §401(a)(9)as in effect prior to the amendments made by the Small Business
Job Pmteclion Act of 1996 (SBJPA).or (3)a Plan where the transition rules belou do not affect any current
Participants.
l’he “required beginning date’for a Participant is.
I.I J April 1st of the calendar year following Ihe year in which the Participant attains age 70 1/2.(pre-SBJPA rules
continue to apply)
2.I J April 1st oithe calendar year following the later of the year in which the Participant attains age 70 1/2 or
retires (the post-SBJPA rules).with the following exceptions (select one or both.leave blank if both applied
effective as of January 3.1996):
a.I I A Participant who was already receiving required minimum distributions under the pre’SBJPA
rules as of ______________________________________(may not be earlier than January I,1996)
was allowed to stop receiving distributions and have them recommence in accordance ~~ith the
posl-SBJPA rules.Upon the recomniencement of distributions.if the Plan permits annuities as a
form of distribution then the following apply:
I.I N/A (annuity distribulions are not permitted)
2.[]Upon the recommencement of distributions.the original Annuity Starting Date will be
retained.
3.I I Upon the recommencement of distributions.a neu Annuity Starting Date is created
b.(J A Participant who had not begun receiving required minimum distributions as of
_________________________________(may not be earlier than January I.1996)ma>elect to defer
comntenccment of distributions until reiirement The option to defer the commencement of
distributions (i.e..to elect to receive in-service distributions upon atlainment of age 70 1/2)applies
to all such Participants unless selected below:
I.I J The in-service distribution option was eliminated with respect to Participants t~’ho
attained age 70 1/2 in or oiler the calendar year that began oiler the later of(I)December
31.1998.or (2)the adoption date of the restatement to bring the Plan into compliance
with the SBJPA.
2020 Nation’~ide Financial Sen ices.Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Got ernmental 401(a)
~DNIINISTRATIVE PROCEOL RES
The following are optional administratne pros isions The Administrator may implement procedures that override any elections in this
Section ~tithout a formal Plan amendment.In addition.nioditications to these procedures will not affect an ltmployer’s reliance on the Plan
A Loan Limitations.(complete only if loans to Participants are permitted:leave blank it’none apply)
a.(XI Limitations (select one or more)
I [XI Loans tt’ill be treated as Participant directed investments.
2.)Loans will only be made for hardship or financial necessity as specified belo’~(select a.orb)
a.[j hardship reasons specified in Plan Section 6 12
b.financial necessity (as defined in the loan program
3 LX)The minimum loan will he $1.000
4 IX)A Participant may only have one (I)(e.g..one (I))loan(s)outstanding at an)’time.
5.All outstanding loan balances will become due and payable in their entirety upon the occurrence of a distributable
event (other than satisfaction of the conditions for an in-service distribution (including a hardship distribution).if
applicable)
6.I I l’he home loan term will be —years.(if not selected,the Admtnistrator establishes the term lhr repay rnent of
a home loan)
7 J ~cconnt restrictions.Loans will only be permitted from the following Participant Accounts (select all that apply
or leave blank it’no limitations apply):
a.[Account(s)attributable to Employer matching contributions
b.()Account attributable to Einploycr contributions other than matching contributions
c.I )Rollover Account
d,I )Transfcr Account
c.I Other.______________________________________________
AND,if loans are restricted to certain accounts,the limitations of Code §72(p)ttill be applied
f I I by deternuning the limits by only considering the restricted accounts.
g.I hy determining the limits taking into account a Participants entire interest in the Plan
Additional Loan Provisions (select all that apply.leave blank if none apply)
b.(XI Loan payments.Loans arc repaid by (if leA blank,then payroll deduction applies unless Participant is not subject to payroll
(e.g..panner who only has a draw)):
I.I I payroll deduction
2.(XI ACII (Automated Clearing [louse)
3.(I check
a (I Only for prepay ment
c IX!Interest rate,loans will be granted at the Iblloiving interest rate (if leA blank,then 3 beloss applies):
I IX!,~_,percentage points over the prime interest rate
2 I J
3 I )the Administrator establishes the rate at the time the loan i made
d.IX)Refinancing.Loan refinancing is allotted.
B Life tosurance,(Plan Section 7.5)
a IXI Life insurance may not be purchased.
b.L J Litë insurance tirny be purchased
I I I at the option of the Administrator
2 I I at the option of the Participant
Limitations
3.J N A (no limitations)
4.1 I The purchase of initiator additional life insurance will be subject to the follotting limitations (select one or more):
a [)Each initial Contract ~till have a minimum face amount of$______
b.[Fach additional Contract ‘till have a minimum face amount of$_______
c I I The Participant has completed —Years (or Periods)of Service.
d ()The Participant has completed Years (or Periods)of Service while a Participant in the Plan.
e (J The Participant is under age on the Contract issue date.
f.I )The maximum amount of all Contracts on behalf of a Participant may not exceed $______
g I I The maximum face amount of any life insurance Contract will be S
C Plan Expenses.Will the Plan assess agatnst an inditidual Participant’s Account certain Plan expenses that are incurred by.or are
attributable to.a particular Participant based on use of a particular Plan service’
a [JNo
b [XI Yes
2020 Nationaide Financial Services.Inc or its su
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
b.(XJ Complete the following UNLESS not selecting supporting forms:
Trustee/Insurer (select a OR one or more of d e)
c I )Insurer.This Plan is funded exclusively “ith Contracts (select one or ntore of I.-4)
Same orinsurer(s)
I.F I _________________
2-(j __________
3 1 I Use Employer address/telephone number/email
4 I I Use following address/telephone number/email
a Street:______________________________
b.City
c.State:______________________________
d Zip:
e Telephone:
I’Email:_______________________
d I I Indi’idual 1 rustee(s)
e IXI Corporate Trustee
\ame oflrust
f Specify name of Trust (required for FIS trust)Citi of[ort Collins Police Plan
lndhidual Trustees (ild.selected above,complete g.—j.)
Directcdlfliscretionary Trustees.The individual Trustee(s)executing this Adoption Agreement are (select g.or h.)
g I I Select for each mdi’idual I rustee (skip to next question)
h.The following selections app1)to all indtvidual irustec(s)(select I -4 as applicable)
I j I A discretionary Trustee over all plan assets (ma>not he selected with 2 -4.)
2 {A nondiscrettonary (directed)I rustee over all plan assets (ma>not be selected with I 3.or 4
3 f The individual 1 rustee(s)will serve as a discretionary 1 rustee over the following assets:________________
(nia)not he selected ~,.ith I or?
4.The individual irustee(s)~~ill serve as a nondiscretionary (directed)I rustec over the Qillo~~ing assets-
_____________(may not be selected with I or 2
Individual Trustee(s)(complele if d selected above)
I I Individual Trustee(s)are (select one or more ofa .j :enter address aij bclo~~)
a,Name ___________
Title/Email:
I.Title _______
2 Email ____________(optional)
Trustee is:(complete if g.selected above,select 3.6.as applicable)
3 I I Discretionary 1 rustee over all plan assets (ma>not be selected with 4.6
4 (I A discretionary Trustee over the following plan assets (may not be select with 3.or 5.)
5 I I Nondiscretionary 1 rustee over all plan assets (may not be selected with 3..4.or 6.)
6 I I A nondiscrctionary (directed)Trustee or Custodian o~cr the following plan assets (ma>not he
selected ‘~ith 3.or 5)
b.Name _______
Title/Email:
I Title __________
2 Email ___________(optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3 [j Discretionary trustee over all plan assets (may not be selected ~~ith 4.6)
4 I I A discretionary Trustee over the following plan assets:___________(may not be select “ith 3.or 5.)
5 [j Nondiscretionary Trustee over all plan assets (may nol be selected with 3..4 or 6)
6 (I A nondiscretionary (directed)Trustee or Custodian over the following plan assets (may not be
selected with 3 or 5
c.Name ________
Title/Email:
I Title ____________
2 Email ___________(optional)
Trustee is:(complete if g selected above:select 3.6.as applicable)
3 (J Discretionary Trustee over all plan assets (may not be selected with 4 6.)
4 I J A discretionary Trustee over the following plan assets:(may not be select with 3 or 5)
5 1 1 Nondiscrettonary Trustee over all plan assets (may not be selected ‘~ith 3..4 or 6)
2020 Nation”ide Financial Services.Inc.or its suppliers
3
EXHIBIT A TO RESOLUTION 2024-072
Non-Standardized Governmental 401(a)
5 1 I Nondiscretionary Trustee over all plan assets (may not be selected with 3..4.cr6.)
6.j j A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(may not be
selected with 3.or 5.)
j.Name ________
Title/Email:
I.Title _______
2,Email ___________(optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3.1 Discretionary Trustee over all plan assets (may not be selected “jib 4 or 6
4.j j A discretionary Trustee over the following plan assets (mu)not be selected ~uth 3 or 5
5.[)Nondiscretionary l’rustee over all plan assets (may not be selected with 3..4.or 6.)
6.[I A nondiscretionary (directed)Trustee or Custodian o’er the following plan assets ___________(nay not be
selected with 3.or 5.)
J.I I Individual Trustee Address (complete if d selected above)
I.I I Use Employer address/telephone number email
2.I I Use following address/telephone number email
a.Street:_____________
b.City:
c.State:_____________
d.Zip:
c.Telephone:
f.Email:
Corporate Trustee Name/Type/Address (complete ile selected above)
Ic.IXI Name Nationwide Trust Contnanv.P58
Address/telephone number/email
I.Use Employer address/telephone number entail
2.IX)Use following address/telephone number email
a.Street:10 West Nationwide Blvd.
b.City:Colunibus
c.State:Ohio
d.Zip:43215
e Telephone:(877)496-1630
1.~
Directed/Discretionary.The Corporate Trustee is (select 3 -6 as applicable)
3 {j A discretionary irustee over all plan assets (ma>not be selected ~‘ith 4 6)
4.~X)A nondiscretionary (directed)1 rustee over all plan assets (may not be selected “tIlt 3..5 or 6)
5.A discretionary Trustee over the following plan assets over the following assets:(ma)riot he
selected s~ith 3.4
6 j j A nondiscretionary (directed)Trustee os Cr the folIo~~ing plan assets (may not be selected ‘~ith 3.
4)
Signce (optional):
7 I I Name of person signing on behalf of the corporate Trustee
8.1 1 Email address of person signing on behalf olthe corporate Trustee ___________
Special Trustee for collection of contributions.The Employer appoints the follo’~ing Special Trustee with the responsibility to
collect delinquent contributions t’opI;ona/i
[XI l%ame Rands 8aile~
Tide:
I.Director.Aceountine
Address/telephone number/email
2.1 J Use Employer address/telephone number email
3.~X)Use following address/telephone number email
a Street:215 N Mason St
1,.City.Fort ollins
c.State:Colorado
d.Zip:80524
e Telephone.970-221-6784
I Email rbailcyafc2ov.com
Custodian(s)\ame/Address .The Custodian(s)are (opl’o’ial)
m.I J Name(s)___________
2020 Nation~.ide Financial Services,Inc or its suppliers
EXHIBIT A TO RESOLUTION 2024-072
ACCEPTANCE OF SPECIAL TRUSTEE
I,the undersigned,accept the appointment as Special Trustee of the City of Fort Collins Police Plan (Plan),and agree to all of the
obligations,responsibilities and duties imposed upon the Special Trustee under the Plan and Trust.The sole responsibility of the Special
Trustee is to collect contributions owed to the Plan.No other Trustee has the responsibility to collect contributions owed to the Plan.
5/22/2024
SPECIAL TRUST E DATE SIGNED