HomeMy WebLinkAbout2022-141-12/20/2022-AUTHORIZING THE MAYOR TO EXECUTE CITY-SPONSORED 401(a) AND 457(b) AMENDED AND RESTATED ADOPTION AGRERESOLUTION 2022-141
OF THE COUNCIL OF THE CITY OF FORT COLLINS
AUTHORIZING THE MAYOR TO EXECUTE CITY-SPONSORED
401(a)AND 457(b)AMENDED AND RESTATED ADOPTION AGREEMENTS AND FIRST
AMENDMENT TO 457(b)PLAN
WHEREAS,with Resolution 2020-077,the City of Fort Collins (the “City”)previously
established a qualified 40 1(a)money purchase plan and 457(b)deferred compensation plan
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;and
WHEREAS,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;and
WHEREAS,with Resolution 2020-077 and Nationwide assistance,the City
established,among other plans,the City of Fort Collins 401(a)Police Plan (“40 1(a)Police
Plan”)and the City of Fort Collins 457(b)Deferred Compensation Plan (“457(b)Plan”);and
WHEREAS,since original approval,the City Council has approved changes to the
plans;and
WHEREAS,when established during the transition to Nationwide,the 457(b)Plan
omitted the six-month waiting period from date of hire for police and dispatch employees to
receive the employer match,which had been in effect prior to the transition and has continued
to be followed;and
WHEREAS,City staff has recommended approval and authorization to execute an
amended and restated adoption agreement for the 457(b)Plan prepared by Nationwide to
include the six-month waiting period and a First Amendment to the 457(b)Plan to make clear
that the waiting period provision is effective retroactively to September 18,2020,when the
City originally adopted the 457(b)Plan;and
WHEREAS,in 2022,certain changes to the status of positions within Fort Collins
Police Services warrant changes to the 401(a)Police Plan,including:(1)removal of the
Director of Police Information Systems role,because the employee’s contract falls under the
control of the Unclassified and Classified Management Employee’s Plan;and (2)removal of
the Police Technical Project Manager role,because the position no longer exists within Fort
Collins Police Services;and
WHEREAS,these changes to the 401(a)Police Plan need to be made within this
calendar year to be effective January 1,2023;and
WHEREAS,City staff has recommended approval and authorization to execute an
amended and restated adoption agreement for the 40 1(a)Police Plan prepared by Nationwide;
and
WHEREAS,the Council desires to authorize the Mayor to execute the adoption
agreements for the 401(a)Police Plan and the 457(b)Plan and the First Amendment for the
457(b)Plan in the forms shown on Exhibit “A”.
NOW,THEREFORE,BE IT RESOLVED BY THE COUNCIL OF THE CITY OF
FORT COLLINS as follows:
Section 1.That the City Council hereby makes any and all determinations and
findings contained in the recitals set forth above.
Section 2.That the Council hereby authorizes the Mayor to execute on behalf of
the city the adoption agreements and First Amendment,attached hereto as Exhibit “A”,and
incorporated herein by this reference.
Passed and adopted at a regular meeting of the Council of the City of Fort Collins this
20th day of December,A.D.2022.r
Mayor
ATtEST:Pro Tern
a
City Clerk
Eligible 457 Plan
ADOPTION AGREEMENT FOR
ELIGIBLE GOVERNMENTAL 457 PLAN
The undersigned Employer,by executing this Adoption Agreement,establishes an Eligible 457 Plan (‘Plan’).The Employer,subject
to the Employer’s Adoption Agreement elections,adopts fully the Plan provisions.This Adoption Agreement,the basic plan document and
any attached Appendices,amendments,or agreements permitted or referenced therein,constitute the Employer’s entire plan document.All
“Election”references within this Adoption Agreement or the basic plan document are Adoption Agreement Elections.All “Article”or
“Section”references are basic plan document references.Numbers In parentheses whi hfollow election numbers are basic plan document
references.Where an Adoption Agreement election calls for the Employer to supply text,the Employer may lengthen any space or line,or
create additional tiers.When Employer-supplied text uses terms substantially similar to existing printed options,all clarifications and
caveats applicable to the printed options apply to the Employer-supplied text unless the context requires otherwise.The Employer makes
the following elections granted under the corresponding provisions of the basic plan document
I.EMPLOYER (Itt).
Name:City of Fort Collins
Address 300 LaPorte Avenue
Street
Fort Collins Colorado 80521
City State Zip
Telephone:(970)221-6535
Taxpayer Identification Number (TIN)84-6000587
2.PLAN NAME.
Name:City of Fort Collins 457(b)Deferred Comoensation Plan
3.PLAN YEAR (1.25).Plan Year means the 12 consecutive month period (except for a short Plan Year)ending every (Choose one of
a.orb,and choose c.~fapplicable,):[Note.Complete any applicable blanks under Election c.with a specifIc date,e.g.,“June 30”OR “the
last day of February”OR “the first Tuesday In January.“In the case of a Short Plan Year or a Sho,’t Limitation Year,include the year,e g
“May I,2i7l3.”j
a.[X]December31.
b.[I Plan sear:ending:
c.[J Short Plan Year:commencing:___________________________and ending:
4.EFFEC1’IVE DATE (1.08).The Employer’s adoption of the Plan is a (Choose one of a.orb.Complete c if new plan OR complete c
and d.if an amendment and restatement.Choose e.(1applicable,)
a.[]New Plan.
b.[XJ Restated Plan.The Plan is a substitution and amendment of an existing 457 plan.
Initial Effective Date of Plan
c.[X]January I.1995 (enter month day.year;hereinafter called the “Effective Date”unless 4d is entered below)
Restatement Effective Date (If this is an amendment and restatement enter effective date of the restatement.)
d.IX]January I,2022 (enter month day,year,)
Special Effective Dates:(optional)
e.j Describe:
5.CONTRIBUTION TYPES.(If this is afrozen Plan (i.e.,all contributions have ceased),choose a.only):
Frozen Plan
a.I ]Contributions cease.All Contributions have ceased or will cease (Plan is frozen).
I.Effective date of freeze:_________________________[Note’Effective date is optional unless this is the amendment or
restatement to freeze the Plan.]
Eligible 457 Plan
Contributions.The Employer andlor Participants,in accordance with the Plan terms,make the following Contribution Types to the Plan
(Choose one or more of b.through d.jfapplicable,):
b.[XJ Pre-Tax Elective Deferrals.The dollar or percentage amount by which each Participant has elected to reduce his/her
Compensation.as provided in the Participants Salary Reduction Agreement (Choose one or more as applicable):
And will Matching Contributions be made with respect to Elective Deferrals?
1.[X~Yes.See Question 16.
2.[]No.
And will Roth Elective Deferrals be made?
3.[X]Yes.[Note:The Employer may not limit Deferrals to Roth Deferrals only]
4.[]No.
c.[I Nonelective Contributions.See Question 17.
d.[XJ Rollover Contributions.See Question 30.
6.EXCLUDED EMPLOYEES (1.10).The following Employees are Excluded Employees and are not eligible to participate in the Plan
(Choose one of a.or bj:
a.I I No exclusions.All Employees are eligible to participate.
b.[X]Exclusions.The following Employees are Excluded Employees (Choose one or more of!.through 4.):
I.[j Part-time Employees.The Plan defines part-time Employees as Employees who normally work less
than ________________hours per week
2.j ]Hourly-paid Employees.
3.j ]Leased Employees.The Plan excludes Leased Employees.
4.jXJ Specify:See Exhibit 2
7.INDEPENDENT CONTRACTOR (1.16).The Plan (Choose one of a.,b.or c.):
a.[]Participate.Permits Independent Contractors to participate in the Plan.
b.IX]Not Participate.Does not permit Independent Contractors to participate in the Plan.
c.j ]Specified Independent Contractors.Permits the ollowing specified Independent Contractors to participate:
[Note:If the Employer elects to permit any or all Independent Contractors to participate in the Plan,the term Employee as used in the
P/a,,includes such participating Independent Contractors]
8.COMPENSATION (1.05).Subject to the following elections.Compensation for purposes of allocation of Deferral Contributions
means:
Base Definition (Choose one o a b.,c.or dj:
a.[]Wages,tips and other compensation on Form W-2.
b.j Code §3401(a)wages (wages for withholding purposes).
c.[j 415 safe harbor compensation.
d.[Xl Alternative (general)415 Compensation.
[Note:The Plan pro vides that the base definition of Compensation includes amounts that are not included in income due to Code ~~40U’k.),
125,1320 4,403 b ,SEP,4149i 2),&457,Compensation for at?Independent Contractor means the amounts the Employer pays to the
Independent Contractor for services,except as the Employer othenvise spec~es below.]
Modifications to Compensation definition.The Employer elects to modify the Compensation definition as follows (Choose one of e.
orf):
e.[X]No modifications.The Plan makes no modifications to the definition.
f.]Modifications (Choose one or more of I through 5.):
I.I ]Fringe benefits.The Plan excludes all reimbursements or other expense allowances,fringe benefits (cash and noncash).
moving expenses,deferred compensation and welfare benefits.
2.[I Elective Contributions.[1.05(E)]The Plan excludes a Participant’s Elective Contributions.
2020 2
Eligible 457 Plan
3.[]Bonuses.The Plan excludes bonuses.
4.[]Overtime.The Plan excludes overtime.
5.[]Specify:
Compensation taken into account.For the Plan Year in which an Employee first becomes a Participant,the Plan Administrator will
determine the allocation of matching and nonelective contributions by taking into account (Choose one ofg.or Ii.):
g.~Plan Year.The Employees Compensation for the entire Plan Year.(‘NA jf no matching or nonelective contributions)
h.]Compensation while a Participant.The Employees Compensation only for the portion of the Plan Year in which the
Employee actually is a Participant.(NA if no matching or nonelective contributions)
9.POST-SEVERANCE COMPENSATION (1.05(F)).Compensation includes the following types of Post-Severance Compensation
paid within any applicable time period as may be required (Choose one of a.or b.):
a.[]None.The Plan does not take into account Post-Severance Compensation as to any Contribution Type except as required under
the basic plan document.
b.[X]Adjustments.The following Compensation adjustments apply (Choose one or more):
I.[Xi Regular Pay.Post-Severance Compensation will include Regular Pay and it will apply to all Contribution Types.
2.(XI Leave-Cashouts.Post-Severance Compensation will include Leave Cashouts and it will apply to all Contribution Types.
3.[I Nonqualified Deferred Compensation.Post-Severance Compensation will include Deferred Compensation and it will
apply to all Contribution Types.
4.[XI Salary Continuation for Disabled Participants.Post-Severance Compensation will include Salary Continuation for
Disabled Participants and it will apply to all Contribution Types.
5.[I Differential Wage Payments.Post-Severance Compensation will include Differential Wage Payments (military
continuation payments)and it will apply to all Contribution Types.
6.[I Describe alternative Post-Severance Compensation definition,limit by Contribution Type,or limit by
Participant group:
10.NORMAL RETIREMENT AGE (1.20).A Participant attains Normal Retirement Age under the Plan (Choose one of a.or bj:
a.[]Plan designation.[Plan Section 3.05(8)]When the Participant attains age ________.[Note The age ma)’not exceed age
70 /2.The age may not be less than age 65.or,if earlier,the age at which a Participant maj retire and receive benefits under
the Employer’s pension plan,ifaiw.]
b.[X]Participant designation.[Plan Section 3.05(8)and (B)(l)]When the Participant attains the age the Participant designates,
which may not be earlier than age 65 and may not be later than age 70 1/2 .[Note:The age mc~’not exceed age 70 I 2.1
Special Provisions for Police or Fire Department Employees (Choose c.and/or d.as applicable):
c.[X]Police department employees.[Plan Section 3.05(B)(3)](Choose I.or 2.):
I.[]Plan designation.[Plan Section 3.05(B)]When the Participant attains age ________.[Note:The age may not exceed age
70 1 2 and ma)’not be less than age 40.]
2.jxj Participant designation.[Plan Section 3.05(B)and (8)0)]When the Participant attains the age the Participant
designates.which may not be earlier than age ....4~..(no earlier than age 40)and may not be later than
age 70 1/2 .[Note:The age ‘nay not exceed age 70 1 2.]
d.[XI Fire department employees.[Plan Section 3.05(B)(3)](Choose 1.or 2.):
I []Plan designation.[Plan Section 3.05(B)]When the Participant attains age [Note The age ma)’not exceed age
0 I 2 and may not be less than age 40.]
2 [X]Participant designation.[Plan Section 3.05(8)and (B)(I)]When the Participant attains the age the Participant
designates,which may not be earlier than age ...4Q...(no earlier than age 40)and may not be later than
age 70 112 .[Note:The age may not exceed age 70 1 2.1
II.ELIGIBILITY CONDITIONS (2.01).(Choose one of a.orb):
a.[X]No eligibility conditions.The Employee is eligible to participate in the Plan as of his/her first day of employment with the
employer.
b.[]Eligibility conditions.To become a Participant in the Plan,an Eligible Employee must satis~’the following eligibility
conditions (Choose one or more oft 2 or 3)
I.[j Age.Attainment of age
2020 3
Eligible 457 Plan
2.[]Service.Service requirement (Choose one of a.orb.):
a.[]Year of Service.One year of Continuous Service.
b.[]Months of Service.________month(s)of Continuous Service.
3.[]Specify:
12.PLAN ENTRY DATE (1.24).Plan Entry Date means the Effective Date and (‘C’hoose one of a.through d.):
a.j ]Monthly.The first day of the month coinciding with or next following the Employees satisfaction of the Plans eligibility
conditions,if any.
b.L ]Annual.The first day of the Plan Year coinciding with or next following the Employees satisfaction of the Plans eligibility
conditions,if any.
c.[X]Date of hire.The Employees employment commencement date with the Employer.
d.j ]Specify:
13.SALARY REDUCTION CONTRIBUTIONS (1.30).A Participants Salary Reduction Contributions under Election Sb.are subject to
the following limitation(s)in addition to those imposed by the Code (Choose one of a.or
a.IX]No limitations.
b.I ]Limitations.(Choose one or more of I.,2.or 3.):
I.I I Maximum deferral amount.A Participants Salary Reductions may not exceed:_______________________(specifj’
dollar amount or percentage of Compensation).
2.I J Minimum deferral amount.A Participants Salary Reductions may not be less than:_______________________(spec~fj’
dollar amount or percentage of ~‘ompensation,)
3.[]Specify:
[Note:Any limitation the Employer elects In b.I through b.3 will apply on a payroll basis unless the Employer othenvise specifies in b 3 1
Special NRA Catch-Up Contributions (3.05).The Plan (Choose one of c.or
c.IX]Permits.Participants may make NRA catch-up contributions.
AND,Special NRA Catch-Up Contributions C’hoose one of!.or 2):(NA if no matching contributions)
I.[X]will be taken into account in applying any matching contribution under the Plan.
2.[]will not be taken into account in applying any matching contribution under the Plan.
d.I I Does not permit.Participants may not make NRA catch-up contributions.
Age SO Catch-Up Contributions (3.06).The Plan (Choose one of e.orfj:
e.[X]Permits.Participants may make age 50 catch-up contributions.
AND,Age 50 Catch-Up Contributions (Choose one of!or 2):(WA if no matching contributions)
I.[Xi will be taken into account in applying any matching contribution under the Plan.
2.[j will not be taken into account in applying any matching contribution under the Plan.
f.[]Does not permit.Participants may not make age 50 catch-up contributions.
14.SICK.VACATION AND BACK PAY (3.02(A)).The Plan (Choose one of a.orb.):
a.LX]Permits.Participants may make Salary Reduction Contributions from accumulated sick pay.from accumulated vacation pay or
from back pay.
b.j ]Does Not Permit.Participants may not make Salary Reduction Contributions from accumulated sick pay.from accumulated
vacation pay or from back pay.
15.AUTOMATIC ENROLLMENT (3.02(B)).Does the Plan provide for automatic enrollment (Choose one of the following)[Note if
Eligible Automatic Contribution Arrangement (EACA),select l5c and complete Questions 31 &32]:
a.IX]Does not apply.Does not apply the Plan’s automatic enrollment provisions.
Eligible 457 Plan
b.[]Applies.Applies the Plan’s automatic enrollment provisions.The Employer as a Pre-Tax Elective Deferral will withhold
________~o from each Participant’s Compensation unless the Participant elects a different percentage (including zero)under
his/her Salary Reduction Agreement.The automatic election will apply to (Choose one of!.through 3.,):
I.J All Participants.All Participants who as of _______________________________are not making Pre-Tax Elective
Deferrals at least equal to the automatic amount.
2.F ]New Participants.Each mployee whose Plan Entry Date is on or following:
3.]Describe Application of Automatic Deferrals:
c.j J EACA.The Plan will provide an Eligible Automatic Contribution Arrangement (EACA).Complete Questions 31 &32.
16.MATCHING CONTRIBUTIONS (3.03).The Employer Matching Contributions under Election Sb.I.are made as follows (Choose
one or mole of a.through d.):
a.[XJ Fixed formula.An amount equal to l000o of each Participant’s Salary Reduction Contributions.
b.[]Discretionary formula.An amount (or additional amount)equal to a matching percentage the Employer from time to time
may deem advisable of each Participant’s Salary Reduction Contributions
c.[]Tiered formula.The Employer will make matching contributions equal to a uniform percentage of each tier of each
Participant’s Salary Reduction Contributions,determined as follows:
NOTE:Fill in only percentages or dollar amounts,but not both.Ilpercentages 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 Oo)
First _______________00
Next ____________00
Next
Next Oo
d.[]Speei&:
Time Period for Matching Contributions.The Employer will determine its Matching Contribution based on Salary Reduction
Contributions made during each (‘Choose one of e.through h.):
e.]Plan Year.
f.[]Plan Year quarter.
g.[X]Payroll period.
h.[I Specify:
Salary Reduction Contributions Taken into Account.In determining a Participant’s Salary Reduction Contributions taken into account
for the above-specified time period under the Matching Contribution formula,the following limitations apply (Choose one of i.through L):
i.[J All Salary Reduction Contributions.The Plan Administrator will take into account all Salary Reduction Contributions.
j.[]Specific limitation.The Plan Administrator will disregard Salary Reduction Contributions exceeding 0~of the
Participant’s Compensation.
k.[]Discretionary.The Plan Administrator will take into account the Salary Reduction Contributions as a percentage of the
Participant’s Compensation as the Employer determines.
I.[XJ Specify:See Exhibit 2
Allocation Conditions.To receive an allocation of Matching Contributions,a Participant must satisfy the following allocation condition(s)
(Choose one of in.or nj:
m.F ]No allocation conditions.
n.LX]Conditions.The following allocation conditions apply to Matching Contributions (Choose one or more of)through 4):
I []Service condition.The Participant must complete the following number of months of Continuous Service during the
Plan Year
2020 5
Eligible 457 Plan
2.[Employment condition.The Participant must be employed by the Employer on the last day of the Plan Year.
3.[J Limited Severance Exception.Any condition specified in I.or 2.does not apply if the Participant incurs a Severance
from Employment during the Plan Year on account of death,disability or attainment ofNormal Retirement Age in the
current Plan Year or in a prior Plan Year.
4.LX]Specify:Police and Dispatchers will become eligible to receive the Employer Match in I 6.a beginning with the pay
period commencing after the 6 month anniversary of their date of hire.
17.NONELECTIVE CONTRIBUTIONS (1.19).The Nonelective Contributions under Election Sc.are made as follows:(Choose one
a.I ]Discretionary -Pro-Rata.An amount the Employer in its sole discretion may determine.
b.[]Fixed -Pro Rata.___________~o of Compensation.
c.[]Other.A Nonelective Contribution may be made as follows:
Allocation Conditions.(3.08).To receive an allocation ofNonelective Contributions,a Participant must satisfy the following allocation
condition(s)(Choose one of d ore)
d.[]No allocation conditions.
e.[]Conditions.The following allocation conditions apply to Nonelective Contributions (Choose one or more of!.through 4.):
I.[]Service condition.The Participant must complete the following number of months of Continuous Service during the
Plan Year:__________
2.]Employment condition.The Participant must be employed by the Employer on the last day of the Plan Year.
3 []Limited Severance Exception.Any condition specified in I.or 2.does not apply if the Participant incurs a Severance
from Employment during the Plan Year on account of death,disability or attainment of Normal Retirement Age in the
current Plan Year or in a prior Plan Year.
4.L I Specify:
IS.TIME AND METHOD OF PAYMENT OF ACCOUNT (4.02).The Plan will distribute to a Participant who incurs a Severance from
Employment his/her Vested Account as follows:
Timing.The Plan,in the absence of a permissible Participant election to commence payment later,will pay the Participants Account
(Choose one of a.through e.):
a.[j Specified Date.days after the Participants Severance from Employment.
b.[X]Immediate.As soon as administratively practicable following the Participant’s Severance from Employment.
c.[I Designated Plan \ear.As soon as administratively practicable in the ________________Plan Year beginning after the
Participants Severance from Employment.
d.[j Normal Retirement Age.As soon as administratively practicable after the close of the Plan Year in which the Participant
attains Normal Retirement Age.
e.f j Specify:
Method.The Plan,in the absence of a permissible Participant election,will distribute the Participant’s Account under one of the following
method(s of distribution Chaos one or mole off throughj as applicable):
f.[X~Lump sum.A single payment.
g.[Xi Installments.Multiple payments made as follows:may not be less than $100
h.[]Installments for required minimum distributions only.Annual payments,as necessary under Plan Section 4.03.
i.[XJ Annuity distribution option(s):Annuity Purchase
J.[]Specify:
Pnrticipnnt Election.[Plan Sections 4.02(A)and (B)]The Plan (Choose one of k.,I.or
k.[X]Permits.Permits a Participant,with Plan Administrator approval of the election,to elect to postpone distribution beyond the
time the Employer has elected in a.through e.and also to elect the method of distribution (including a method not described in
f.through).above).
I []Does not permit.Does not permit a Participant to elect the timing and method of Account distribution.
m []Speci~’:
2020 6
Eligible 457 Plan
Mandatory Distributions.Notwithstanding any other distribution election,following Severance from Employment (Choose ii.or oj:
n [XJ No Mandatory Distributions.The Plan will not make a Mandatory Distribution.
o.[]Mandatory Distribution.If the Participants Vested Account is not in excess of $5,000 (unless a different amount selected
below)as of the date of distribution.the Plan will make a Mandatory Distribution following Severance from Employment.
Mandatory Distribution.If the Participant’s Vested Account is not in excess of$_____________as of the date of
distribution,the Plan will make a Mandatory Distribution following Severance from Employment.
Rollovers in determination of $5,000 threshold.Unless otherwise elected below,amounts attributable to rollover contributions (if any)
will be included in determining the $5,000 threshold for timing of distributions,form of distributions or consent rules.
p.]Exclude rollovers (rollover contributions will be excluded in determining the $5.000 threshold)
NOTE:Regardless of the above election,if 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.
19.BENEFICIARY DISTRIBUTION ELECTIONS.Distributions following a Participant’s death will be made as follows (Choose one
of a.thro ugh d):
a.[I Immediate.As soon as practical following the Participant’s death.
b.[I Next Calendar Year.At such time as the Beneficiary may elect,but in any event on or before the last day of the calendar year
which next follows the calendar year of the Participant’s death.(N A ~fparticipant is restricted)
c.(XI As Beneficiary elects.At such time as the Beneficiary may elect,consistent with Section 4.03.(7~’A ~fparticipant is restricted)
d.j ]Describe:
[Note.The Employer under Election 19d.may describe an alternative distribution liming or afford the Beneficiary at?election which is
narrower than that perm itted under Election I9c.,or include special provisions ,‘elated to certain beneficiaries,(e.g.,a surviving spouse).
However,any election under Election 19d.must require distribution to commence no later than the Section 4.03 required date.]
20.DISTRIBUTIONS PRIOR TO SEVERANCE FROM EMPLOYMENT (4.05).A Participant prior to Severance from Employment
may elect to receive a distribution of his/her Vested Account under the following distribution options (Choose one of a.orb.):
a.I I None.A Participant may not receive a distribution prior to Severance from Employment.
b.[X]Distributions.Prior to Severance from Employment are permitted as follows (Choose one or more of).through 4.):
I.[X]Unforeseenble emergency.A Participant may elect a distribution from his/her Account in accordance with Plan Section
4.05(A)(for the Participant,spouse,dependents or beneficiaries)
2.[XI De minimis exception.[Plan Section 4.05(B)]If the Participant:(i)has an Account that does not exceed $5,000;(ii)has
not made or received an allocation of any Deferral Contributions under the Plan during the two-year period ending on the
date of distribution;and (iii)has not received a prior Plan distribution under this de minimis exception.then (Choose one
of a,b.o,’c.):
a.I ]Participant election.The Participant may elect to receive all or any portion of his/her Account.
b.j I Mandatory distribution.The Plan Administrator will distribute the Participant’s entire Account.
c.[X]Hybrid.The Plan Administrator will distribute a Participant’s Account that does not exceed $1.000 and the
Participant may elect to receive all or any portion of his/her Account that exceeds $1,000 but that does not
exceed $5,000.
3.jX]Age 70 1/2.A Participant who attains age 70 1/2 prior to Severance from Employment may elect distribution of any or all
of his/her Account.
4.]Specify:
[Note:An Employer need not permit any in-service distributions.Any election must comp y with the distribution i-estncttons of Cod
Section 457(d).]
2!.ODRO (4.06).The QDRO provisions (Choose one of a.,b,or
a.[X]Apply.
b.[]Do not apply.
c.[I Specify:
Eligible 457 Plan
22.ALLOCATION OF EARNINGS (5.07(8)).The Plan allocates Earnings using the following method (Choose one or more of a.
throughf):
a.[XI Daily.See Section 5.07(B)(4)(a).
b.]Balance forward.See Section 5.07(B)(4)(b).
c.[]Balance forward with adjustment.See Section 5.07(B)(4)(c).Allocate pursuant to the balance forward method,except treat
as part of the relevant Account at the beginning of the Valuation Period _________°o of the contributions made during the
following Valuation Period:_________________________
d.[]Weighted average.See Section 5.07(B)(4)(d).If not a monthly weighting period,the weighting period is
e.L ]Directed Account method.See Section 5.07(B)(4)(e).
f.[]Describe Earnings allocation method:___________________________________________________________________________
[Note:The Employer under Election 22f may describe Earnings allocation methods from the elections available under Election 22 and/or
a combination thereof as to any:(i)Participant group (e.g.,Daily applies to Division A Employees OR to Employees hired after “s‘date.
Balance forward applies to Division B Employees OR to Employees hired on before “x”date)(ii Contribution Type (e.g.,Daily applies
as to Discretionary Nonelective Contribution Accounts Participant Directed Account applies to Fixed Nonelective Contribution
Accounts);(iii)investment type,investment vendor or Account type e g..Balance orward applies to investments placed with vendor A and
Participant-Directed Account applies to investments placed with vendor B OR Daily applies to Participant -DirectedAcco unts and balance
forward applies to pooled Accounts).I
23.HEART ACT PROVISIONS (l.31(C)(3)/3.13).The Employer elects to (Choose one of a orb andc ordi
Continued Benefit Accruals.
a.[]Not apply the benefit accrual provisions of Section 3.13.
b.[X]Apply the benefit accrual provisions of Section 3.13.
Distributions for deemed severance of employment (1.31(C)(3))
c [X]The Plan does NOT permit distributions for deemed severance of employment.
d.]The Plan permits distributions for deemed severance of employment.
24 VESTING/SUBSTANTIAL RISK OF FORFEI1’URE (5.1 t).A Participants Deferral Contributions are [Note:If a Participant incurs
a Severance from Employment before the spec~ed events or conditions,the Plan willforfeit the Participant’s non-vested Account.Caution:
fa Dc erral is subject to vesting schedule or other substantial risk offoifeiture,it does not count as a deferralfor purposes of the annual
deferral limit until the year it is fully vested.](Choose all that apply of a.through d.):
a.[Xi 100%Vested/No Risk of Forfeiture.Immediately Vested without regard to additional Service and no Substantial Risk of
Forfeiture.The following contributions are IOO0o Vested:
I.[XI All Contributions.(skip to 25.)
2.[]Only the following contributions.(select all that apply):
a.[]Salary Reduction Contributions.
b.[]Nonelective Contributions.
c.[J Matching Contributions.
b.]Forfeiture under Vesting Schedule.Vested according to the following:
Contributions affected.The following contributions are subject to the vesting schedule (Choose one or more of!..2.or 3.):
I.[J Salnry Reduction Contributions.
2 []Nonelective Contributions.
3 1 1 Matching Contributions.
4.[]Vesting Schedule.
Years of Service Vested Percentage
____%
____%
____%
___%
Eligible 457 Plan
For vesting purposes,a “Year of Service”means:
5.
F Note:Itis extremely rare to apply a vesting schedule to Salary Reduction Contributions.]
c.F ]Substantial Risk of Forfeiture.Vested only when no longer subject to the following Substantial Risk of Forfeiture as follows:
Contributions affected.The following contributions are subject to the substantial risk of forfeiture under c.(Choose one or more of
I.,2.or3.):
I.[]Salary Reduction Contributions.
2.F I Nonelective Contributions.
3.L ]Matching Contributions.
Risk Provisions:Vested only when no longer subject to the following Substantial Risk of Forfeiture as follows (Choose one of 4 or
5):
4.[]The Participant must remain employed by the Employer until ,unless earlier Severance from
Employment occurs on account of death or disability,as the Plan Administrator shall establish.
5.[1 Speci~’:
Additional Provisions (Choose d,((applicable)
d.I ]Specify:
FORFEITURE ALLOCATION.[Plan Sections 5.11(A)and 5.14]The Plan Administrator will allocate any Plan forfeitures as selected
below.The Employer has the option louse forfeitures to pay plan expenses first and then allocate the remaining forfeitures in accordance
with the selections below:(Choose one of the following):
e.[]Additional Contributions.As the following contribution type (Choose one of I.or 2.):
I.[]Nonelective.As an additional Nonelective Contribution.
2.[]Matching.As an additional Matching Contribution.
f.[]Reduce Fixed Contributions.To reduce the following fixed contribution (Choose one of).or 2.):
I.[j Nonelective.To reduce the Employers fixed Nonelective Contribution.
2.j Matching.To reduce the Employer’s fixed Matching Contribution.
g.[j Specify:
25.TRUST PROVISIONS.The following provisions apply to Article VIII of the Plan (Choose as applicable:leave blank if not
applicable):
a.[]Modifications.The Employer modifies the Article VIII Trust provisions as follows:______________________________.The
remaining Article VIII provisions apply.
b.[X]Substitution.The Employer replaces the Trust with the Trust Agreement attached to the Plan.
26.CUSTODIAL ACCOUNT/ANNUITY CONTRACT (8.16).The Employer will hold all or part of the Deferred Compensation in one
or more custodial accounts or annuity contracts which satisfy the requirements of Code §457(g)(thoose a.ot b.,c.if applicable):
a.[]Custodial account(s).
b.I ]Annuity contract(s).
c.[]Specif~’:
[Note:The Employer under c.may wish to identift the custodial accounts or annuity contracts or to designate a portion of the Deferred
Compensation to be held in such vehicles versus held in the Trust.]
27.VALUATION.In addition to the last day of the Plan Year.the Trustee (or Plan Administrator as applicable)must value the Trust
Fund (or Accounts)on the following Valuation Date(s)(Choose one of a.orb):
a.[]No additional Valuation Dates.
b.LX]Additional Valuation Dates.(Choose one or more of).,2.or 3):
I.[X]Daily Valuation Dates.Each business day of the Plan Year on which Plan assets for which there is an established market
are valued and the Trustee or Employer is conducting business.
2.[]Last day of a specified period.The last day of each ______________of the Plan Year.
2020 9
Eligible 457 Plan
3.[]Specified Valuation Dates:________________________________________________________________________________
[Note:The Employer under Election 26b.3.may describe Valuation Dates from the elections available under Election 26b.and/or a
combination thereof as to any:(i)Participant group (e.g.,No additional Valuation Dates apply to Division A Employees OR to Employees
hired after “x”date.Daily Valuation Dates apply to Division B Employees OR to Employees hired on/before ‘~r”date.);(ii)Contribution
Type (e.g.,No additional Valuation Dates apply as to Discretionary Nonelective Contribution Accounts.The last day of each Plan Year
quarter applies to Fixed Nonelective Contribution Accounts):(iii)investment type,investment vendor or Account type (e.g..No additional
Valuation Dates apply to investments placed with vendor A and Daily J’aluation Dates apply to investments placed with vendor B OR Daily
Valuation Dates apply to Participant-Directed Accounts and no additional Valuation Dates apply to pooled Accounts)I
28.TRUSTEE (Select all that apply:leave blank if not applicable.):
a.[]Individual Trustee(s)who serve as Trustee(s)over assets not subject to control by a corporate Trustee.(Add additional Trustees
as necessary.)
Name(s)Title(s)
Address and Telephone number (Choose one of).or 2.):
I.[j Use Employer address and telephone number.
2.1 j Use address and telephone number below:
Telephone
b.[XJ Corporate Trustee
Address:10 West Nationwide Rlvd.
Street
Columbus Ohio 43215
City State Zip
Telephone:(614)435-5633
AND,the Corporate Trustee shall serve as:
c.[X]a Directed (nondiscretionary)Trustee over all Plan assets except for the following:
d.[]a Discretionary Trustee over all Plan assets except for the following:
29.PLAN LOANS (5.02(A)).The Plan permits or does not permit Participant Loans (Choose one of a orb.):
a.jX]Does not permit.
b.j J Permitted pursuant to the Loan Policy.
30.ROLLOVER CONTRIBUTIONS (3.09).The Rollover Contributions under Election s.d.are made as follows:
Who may roll over (Choose one of a orb.):
a.IX]Participants only.
Address:
Street
City
Name:Nationwide Trust Comnany
State Zip
b.[J Eligible Employees or Participants.
Eligible 457 Plan
SourcesIl’ypes.The Plan will accept a Rollover Contribution (Choose one of c.ord.):
c.[X]All.From any Eligible Retirement Plan and as to all Contribution Types eligible to be rolled into this Plan.
d.[Limited.Only from the following types of Eligible Retirement Plans and/or as to the following Contribution Types:
Distribution of Rollover Contributions (Choose one of e.,f org.):
e.[Xi Distribution without restrictions.May elect distribution of his/her Rollover Contributions Account in accordance with Plan
Section 4.05(C)at any time.
f.[]No distribution.May not elect to receive distribution of his/her Rollover Contributions Account until the Plan has a
distributable event under Plan Section 4.01.
g.[]Specify:
3!.EACA Automatic Deferral Provisions (3.14).
Participants subject to the Automatic Deferral Provisions.The Automatic Deferral Provisions apply to Employees who become
Participants after the Effective Date of the EACA (except as provided in d.below).Employees who became Participants prior to such
Effective Date are subject to the following (a.d.are optional):
a.F ]All Participants.All Participants.regardless of any prior Salary Reduction Agreement.unless and until a Participant makes an
Affirmative Election after the Effective Date of the EACA.
b F ]Election of at least Automatic Deferral amount.All Participants,except those who,on the Effective Date of the EACA.arc
deferring an amount which is at least equal to the Automatic Deferral Percentage.
c [J No existing Salary Reduction Agreement.All Participants,except those who have in effect a Salary Reduction Agreement on
the effective date of the EACA regardless of the Salary Reduction Contribution amount under the Agreement.
d.I ]Describe:
Automatic Deferral Percentage.Unless a Participant makes an Affirmative Election,the Employer will withhold the following Automatic
Deferral Percentage (select c.or fj:
e.[]Constant.The Employer will withhold ____________°oof Compensation each payroll period.
Escalation of deferral percentage (select one or lcave blank if not applicable)
I.j J Scheduled increases.This initial percentage vill increase by ~o of Compensation per year up to a
maximum of____________of Compensation.
2.[]Other (described Automatic Deferral Percentage):
Automatic Deferral Optional Elections
f.[]Optional elections (select all that apply or Icave blank if not applicable)
Suspended Salary Reduction Contributions.If a Participants Salary Reduction Contributions are suspended pursuant to a
provision of the Plan (e.g.,distribution due to military leave covered by the HEART Act),then a Participant’s Affirmative Election
will expire on the date the period of suspension begins unless other’vise elected below
I.[J A Participant’s Affirmative Election will resume after the suspension period.
Special Effective Date.Provisions will be effective as of the earlier of the Effective Date of the EACA provisions unless otherwise
specified below.
2.j I Special Effective DateS
32.In-Plan Roth Rollover Contributions.
a.IX]Yes,allo~.ed.
Effective Date (enter date)
I.[Xj In-Plan Roth Rollover Effective Date:Januar 1.2013
33.In-Plan Roth Rollover Transfers.
a.[X]Yes,allowed.
Effective Date (enter date)
I.[X)In-Plan Roth Rollover ransfers Effective Date:January 1.2013
Eligible 457 Plan
This Plan is executed on the date(s)specified below:
Use of Adoption Agreement.Failure to complete properly the elections in this Adoption Agreement may result in disqualification of the
Employer’s Plan.The Employer only may use this Adoption Agreement only in conjunction with the corresponding basic plan document.
Separate Trust Agreement.An executed copy of the trust agreement must be attached to this Plan The responsibilities,rights and powers
of the Trustee shall be those specified in the trust agreement.The signature of the Trustee appears on the separate trust agreement
EMPLOYER:City of Fort Collins
By
DATE SIGNED
EXHIBIT B
FIRST AMENDMENT TO THE CITY OF FORT COLLINS 457(B)DEFERRED
COMPENSATION PLAN
WHEREAS,the City of Fort Collins (“Plan Sponsor”)selected Nationwide Retirement Solutions (“NRS”)to
be the recordkeeper of the City of Fort Collins 457(b)Deferred Compensation Plan (“Plan”);
WHEREAS,the Plan Sponsor originally adopted NRS’s Eligible Governmental 457 Plan document
effective September 18,2020;
WHEREAS,the Plan Sponsor restated the Plan effective October 1,2021;
WHEREAS,the Plan Sponsor and NRS has determined that Section 16.n.of the Adoption Agreement
does not properly reflect the eligibility requirement Police and Dispatchers to receive Employer Match;
WHEREAS,Section 16.n.4.needs to be clarified to reflect that Police and Dispatchers have always been
required to wait 6 months from their hire date before they can receive Employer Match;
NOW,THEREFORE,the Plan Sponsor is executing this amendment to clarify that Police and Dispatchers
must complete an initial 6 month waiting period to receive Employer Match.
Section 16.n.4.is amended effective September 18,2020,to clarity to read as follows:
4.[x]Specify:Police and Dispatchers will become eligible to receive the Employer Match in 16.a.
beginning with the pay period commencing after the 6 month anniversary of their date of hire.
IN ALL OTHER RESPECTS,the Plan is hereby confirmed.
The foregoing First Amendment to the City of Fort Collins 457(b)Deferred Compensation Plan is
executed on this day of ________________202_.
E CITY OF FORT COLLINS
By:____________________
[Name]
EXHIBIT C
Non-Standardized Governmental 401(a)
ADOPTION AGREEMENT FOR
NATIONWIDE FINANCIAL SERVICES,INC.
NON-STANDARDIZED
GOVERNMENTAL 401(a)PRE-APPROVED PLAN
CAUTION:Failure to properly fill out this 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,TELEPHONE NUMBER.TIN AND FISCAL YEAR
Name:City of Fort Collins
Address:300 LaPorte Avenue
Street
Fort Collins Colorado 80521
City State Zip
Telephone:(970)221-6535
Taxpayer Identification Number (TIN):84-6000587
Employe?s Fiscal Year ends:December31
2.TYPE OF GOVERNMENTAL 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.j ]State government or state agency
b.j ]County or county agency
c.jXJ Municipality or municipal agency
d.[]Indian tribal government (see Note below)
NOTE:An Indian tribal government may only adopt this Plan if such entity is defined under Code §770I(a)(40),is a subdivision
of an Indian tribal government as determined in accordance with Code §7871(d).or is an agency or instrumentality of eithcr.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 of commercial 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.[X]No
b.[]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.[]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 of Fort Collins Police Plan
5.PLAN STATUS
a.[I New Plan
b.[XI Amendment and restatement of existing Plan
CYCLE 3 RESTATEMENT (leave blank if not applicable)
I.[X]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 (Plan Section 1.16)(complete a.if new plan;complete a.AND b.if au amendment and restatement)
Initial Effective Date of Plan (except for restatements,cannot be earlier than the first day of the current Plan Year)
a.January I.2007 (enter month day,year)(hereinafter called the “Effective Date unless 6.b.is
entered below)
2020 Nationwide Financial Services,Inc or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
Restatement Effective Date.lfthis is an amendment and restatement,the effective date of the restatement (hereinafter called the
Effective Date’)is:
b.January I.2022 (enter month day,year;NOTE:The restatement date may not be prior to the first
day of the current Plan Year.Plan contains appropriate retroactive effective dates with respect to provisions for appropriate
laws.)
7.PLAN YEAR (Plan Section 1.43)means,except as otherwise provided in d.below
a.[X]the calendar year
b.[I the twelve-month period ending on _____________(e.g.,June 30th)
SHORT PLAN YEAR (Plan Section 1.47).This is a Short Plan Year (if the effective date of participation is based on a Plan
Year.then coordinate with Question 14):
c.IX]NA
d.[]beginning on __________________________(enter month day.year;e.g.,July I.2020)
and ending on __________________________(enter month day.year).
8.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.[)the last day of each Plan Year quarter
d []other (specify day or days):____________________________________(must be at least once each Plan Year)
NOTE:The Plan always permits interim valuations.
9.ADMINISTRATOR’S NAME.ADDRESS AND TELEPHONE NUMBER
(Tfnone 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.I ]Other:
Name:
Address:____________________________________________________________________________________________
Street
City State Zip
Telephone:
tO.TYPE OF PLAN (select one)
a.[I Profit Sharing Plan.
b [X]Money Purchase Pension Plan.
II.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 ]This is a frozen Plan (i.e.,all contributions cease)(if this is a temporary suspension.select a.2):
I.I ]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.j ]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 date 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.IX]Employer contributions other than matching (Questions 24-25)
I.[I This Plan qualifies as a Social Security Replacement Plan (Question 24.e.must be selected)
c.[]Employer matching contributions (Questions 26-28)
d.[X]Mandatory Employee contributions (Question 30)
2020 Nationwide Financial Services,Inc.or its suppliers
2
EXHIBIT B
e.[X]After-tax voluntary Employee contributions
f.[X]Rollover contributions (Question 36)
Non-Standardized Governmental 401(a)
PRIOR CONTRIBUTIONS
The Plan used to permit,but no longer does,the following contributions (choose all that apply,if any):
g.[]Employer matching contributions
h.j ]Employer contributions other than matching contributions
i.[]Rollover contributions
j.[]After-tax voluntary Employee contributions
ELIGIBILITY REQUIREMENTS
12.ELIGIBLE EMPLOYEES (Plan Section 117)means all Employees (including Leased Employees)EXCEPT those Employees
who are excluded below or elsewhere in the Plan:(select a.orb.)
a.j No excluded Employees.There are no additional excluded Employees under the Plan (skip to Question 13).
b.[X]Exclusions.The following Employees are not Eligible Employees for Plan purposes (select one or more):
I.r ]Union Employees (as defined in Plan Section 1.17)
2.]Nonresident aliens (as defined in Plan Section 1.17)
3.j ]Leased Employees (Plan Section 1.29)
4.L ]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 1.55).
5.]Temporary Employees.A temporary Employee is an Employee who is categorized as a temporary Employee
on the Employer’s payroll records.
6.[]Seasonal Employees.A seasonal Employee is an Employee who is categorized as a seasonal Employee on
the Employer’s payroll records.
7.[X]Other:An Eli8ible Emolovee for Plan Purooses shall mean any person employed in the followinc Eli2ible
Groups:Sworn Police Officer (excluding Chief of Police).Dispatcher.Dispatcher Supervisor and Dispatch
Mana2er (must be definitely determinable under Regulation §1.401-1(b).Exclusions may be employment
title specific but may not be by individual name)
NOTE:If option 4.-6.(part-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 Hours of Service method will be used for the I Year of Service override regardless of any contrary
selection at Question 16.
No age requirement
Age 20 1/2
comp eted within the computation period)(must satis&the Notes below)
NOTE:If c.4.or d.7.is selected,the condition must be an age or service requirement that is definitely determinable and may
not exceed 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.
Waiver of conditions.The service andlor age requirements specified above will be waived in accordance with the following
(leave blank if there are no waivers of conditions):
e.[]If employed on ________________the following requirements,and the entry date 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 1.and/or 2.AND 3.if applicable):
I.[}service requirement (may let part-time Eligible Employees into the Plan)
13.CONDITIONS OF ELIGIBILITY (Plan Section 3.1)
a.jX]No age and service required.No age and service required for all Contribution Types (skip to Questton 14).
b.F Eligibility.An Eligible Employee will be eligible to participate in the Plan upon satisfaction of the following (complete
c.and d.,select e.and f.if applicable):
Eligibility Requirements
c.j ]Age Requirement
I.[]
2.[]
3.[]Age2l
4.[]Age (may not exceed 26)
d.I ]Service Requirement
I.[]No service requirement
2.[]______(not to exceed 60)months of service (elapsed time)
3.[]I Year of Service
4.[]_______(not to exceed 5)Years of Service
5.j j consecutive month period from the Eligible Employee’s employment commencement date and during
which at least _______Hours of Service are completed.
6.[I _______consecutive months of employment.
7.[]Other:(e g.,date on which 1,000 Hours of Service is
2020 Nationwide Financial Services,Inc.or its suppliers
3
EXHIBIT B
Non-Standardized Governmental 401(a)
2.F ]age requirement
3.[]waiver is for:________________________________
Amendment or restatement to change eligibility requirements
C.[J This amendment or restatement (or a prior amendment and restatement)modified the eligibility requirements and the
prior eligibility conditions continue to apply to the Eligible Employees specified below.If this option is NOT selected,
then all Eligible Employees must satis&the eligibility conditions set forth above.
I.[]The eligibility conditions above only apply to Eligible Employees who were not Participants as of the
effective date of the modification
2.[]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 of the:
a.[]date such requirements are met
b.[]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 met
d.[]earlier of the first day of the Plan Year or the first day of the seventh month of the Plan Year coinciding with or next
following the date on which such requirements are met
e.[]first day of the Plan Year coinciding with or next following the date on which such requirements are met
f.j ]first day of the Plan Year in which such requirements are met
g.F I first day of the Plan Year in which such requirements are met,if such requirements are met in the 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 of
the Plan Year.
h.jXJ other:First payroll after meeting Eligibility (must be definitely determinable)
SERVICE
IS RECOGNITION OF SERVICE WITH OTHER EMPLOYERS (Plan Sections 1.40 and 1.55)
a.[Xl No service with other employers is recognized except as otherwise required by law (e.g.,the Plan already provides for
the recognition of service with Employers who have adopted this Plan as well as service with Affiliated Employers and
predecessor Employers who maintained this Plan;skip to Question 16).
b.[j Service with the designated employers is recognized as follows (select c.e.and 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)
1.2.3.
Contribution
Other Employer Eligibility Vesting Allocation
c.F ]Employername:[][][]
d.[]Employername:I I I ]I I
e.[]Employername:I I I I I I
Limitations
f I I The following provisions or limitations apply with respect to the [][
recognition of prior service:_____________________________________
(e.g.,credit service with X only on/following 1119)
g.[I 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 entities the Employer acquires after
I 118)
NOTE:If the other Employer(s)maintained this qualified Plan,then Years (and/or Periods)of Service with such Employer(s)
must be recognized pursuant to Plan Sections 1.40 and 1.55 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 otherwise elected below:
1.A Year of Service means completion of at least 1.000 Hours of Service during the applicable computation period.
2.Hours of Service (Plan Section 1.24)will be based on actual Hours of Service except that for Employees for whom
records of actual Hours of Service are not maintained or available (e.g.,salaried Employees),the monthly
equivalency will be used.
2020 Nationwide Financial Services,Inc.or its suppliers
4
EXHIBIT B
Non-Standardized Governmental 401(a)
3.For eligibility purposes,the computation period will be as defined in Plan Section 1.55 (i.e.,shill to the Plan Year if
the eligibility condition is one (1)Year of Service or less).
4.For vesting,allocation,and distribution purposes,the computation period will be the Plan Year.
5.Upon an Employee’s rehire,all prior service with the Employer is taken into account for all purposes.
a.LX]Elapsed time method.(Period of Service applies instead of Year of Service)Instead of Hours of Service,elapsed time
will be used for:
I.[X]all purposes (skip to Question 17)
2.[the following purposes (select one or more):
a.[]eligibility to participate
b.[]vesting
c.[]allocations,distributions and contributions
b.[j Alternative definitions for the Hours of Service method.Instead of the defaults,the following alternatives will apply
for the Hours of Service method (select one or more):
I.j ]Eligibility computation period.Instead of shifting to the Plan Year,the eligibility computation period after
the initial eligibility computation period will be based on each anniversary of the date the Employee first
completes an Hour of Service
2.[]Vesting computation period.Instead of the Plan Year,the vesting computation period will be the date an
Employee first performs an Hour of Service and each anniversary thereof.
3.[j Equivalency method.Instead of using actual Hours of Service,an equivalency method will be used to
determine Hours of Service for:
a.[]all purposes
b.[]the following purposes (select one or more):
I.I I eligibility to participate
2.1 ]vesting
3.j ]allocations,distribution and contributions
Such method will apply to:
c.F I all Employees
d.j ]Employees for whom records of actual Hours of Service are not maintained or available
(e.g.,salaried Employees)
e.j ]other:_______________________________________________(e.g.,per-diem Employees only)
Hours of Service will be determined on the basis oe
f.[]daysworked(Iohoursperday)
g.[]weeks worked (45 hours per week)
h.[]semi-monthly payroll periods worked (95 hours per semi-monthly pay period)
i.[]months worked (190 hours per month)
j.[]bi-weekly payroll periods worked (90 hours per bi-weekly pay period)
k.[]other:_______________________________________________(e.g.,option f.is used for per-diem
Employees and option g.is used for on-call Employees).
4.[]Number of Hours of Service required.Instead of 1,000 Hours of Service.Year ofService means the
applicable computation period during which an Employee has completed at least (not to exceed
1,000)Hours of Service for:
a.I ]all purposes
b.[]the following purposes (select one or more):
I.[]eligibility to participate
2.[j vesting
3.j allocations,distributions and contributions
c.L ]Alternative for counting all prior service.Instead of the default which recognizes all prior service 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
2.1 ]the following purposes (select one or more):
a.I I eligibility to participate
b.j ]vesting
c.j ]sharing in allocations or contributions
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
d.I ]Other service crediting provisions:_____________________________________(must be definitely determinable;e.g.,
for vesting a Year of Service 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 will be used for
I.L J Allpurposes
2.j J The following purposes (select one or more):
a.[]eligibility to participate
b.[I vesting
c.[I allocations,distributions and contributions
VESTING
17.VESTING OF PARTICIPANVS INTEREST EMPLOYER CONTRIBUTIONS (Plan Section 6.4(b))
a [N A (no Employer contributions:skip to Question 19)
b.[X]The vesting provisions selected below apply.Section B of Appendix A can be used to speci&any exceptions to the
provisions below.
NOTE:The Plan provides that contributions for converted sick leave and/or vacation leave are fully Vested.
Vesting for Employer contributions other than matching contributions
c.[]N A (no Employer contributions (other than matching contributions);skip to f.)
d.j ]IOO°o vesting.Participants are 100%Vested in Employer contributions (other than matching contributions)upon
entering Plan.
e.jX]The following vesting schedule,based on a Participants 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°o;2 years-20°o;3 years-40°o;4 years-6O°o;5 years-80°o;6 years-l00°o
2.[]4 Year Graded:I year-25°o;2 years-50°o:3 years-75°o;4 years-l00°o
3.j ]5 Year Graded I year-20°o;2 years-40°o;3 years-60°o;4 years-80°o:5 years-I00°o
4.[X]ClifE 100%vesting after three (3~(not to exceed 15)years
5.j J 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 Service Percentage
%
%
%
____%
____%
___%
%
%
%
Vesting for Employer matching contributions
f.[X]N A (no Employer matching contributions)
g.j ]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.[]The following vesting schedule,based on a Participant’s Years of Service (or Periods of Service if the elapsed time
method is selected),applies to Employer matching contributions:
I.[]6 Year Graded:0-I year-0°o.2 years-20°o;3 years-40°o:4 years-60°o:5 years-SO°o;6 years-I00°o
2.j ]4 Year Graded.I year-25°o.2 years-50°o;3 years-75°o:4 years-I OO0o
3.1 ]5 Year Graded.I year-20°o.2 years-40°o;3 years-60°o;4 years-80°o;S years-I 00%
4.[J Cliff:I 00°o vesting after (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)
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
Years (or Periods)of Service Percentage
____%
%
%
%
%
%
____%
___%
___%
NOTE:If any Pan-time/Seasonal/Temporary Employees who are not covered under Social Security are participating in this
Plan as a Social Security Replacement Plan,any contributions used to satisfy the minimum contribution requirements
of Question 24.e will be tOO°~vested.
18.VESTING OPTIONS
Excluded vesting service.The following Years of Service will be disregarded for vesting purposes (select all that apply:leave
blank if none apply):
a.j ]Service prior to the initial Effective Date of the Plan or a predecessor plan (as defined in Regulations §1.41 I(a)-5(b)(3))
b.[]Service prior to the computation period in which an Employee has attained age
c.j ]Service during a period for which an Employee did not make mandatory Employee contributions.
Vesting for death,Total And Permanent Disability and Early/Normal Retirement.Regardless of the vesting schedule,a
Participant will become fully Vested upon (select all that apply;leave blank if none apply)
d.[Xl Death
e.[XJ Total and Permanent Disability
f.[]Early Retirement Date
g.[X]Normal Retirement Age
RETIREMENT ACES
19.NORMAL RETIREMENT AGE (“NRA”)(Plan Section 1.33)means:
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 [X]Specific age.The date a Participant attains age 55
b.L ]Age/participation.The later of the date a Participant attains age _______or the anniversary of the first day of
the Plan Year in which participation in the Plan commenced
c.L ]Other:____________________(must be definitely determinable)
NOTE:If this is a Money Purchase Pension Plan and in-service distributions at Normal Retirement Age are permitted,then the
Normal Retirement Age cannot be less than age 62.or age 50 if substantially all Participants are qualified public safety
employees (as defined in Code §72(Q(I)).The ‘substantially all’requirement for qualified public safety employees will
no longer be a requirement as of the effective date of the final regulations once they 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 after the later of (I)January 1,2015,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.[X]Age 55 (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 1.34)means,with respect to any Participant.the:
a.IX]date on which the Participant attains “NRA”
b.j first day of the month coinciding with or next following the Participant’s “NRA”
c.[J first day of the month nearest the Participant’s “NRA”
d.[I Anniversary Date coinciding with or next following the Participant’s “NRA”
e.[Anniversary Date nearest the Participant’s “NRA”
f.j ]Other:________________(e.g..first day of the month following the Participant’s “NRA”).
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
21.EARLY RETIREMENT DATE (Plan Section 1.15)
a.[X]N A (no early retirement provision provided)
b.[]Early Retirement Date means the:
1.[I date on which a Participant satisfies the early 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.]Anniversary Date coinciding with or next following the date on which a Participant satisfies the early
retirement requirements
Early retirement requirements
4.[]Participant attains age
AND,completes....(leave blank if not applicable)
a.[]at least _______Years (or Periods)of Service for vesting purposes
b.[]at least _______Years (or Periods)of Service for eligibility purposes
c.[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.LXI Wages,tips and other compensation on Form W-2
b.j I Code §3401(a)wages (wages for withholding purposes)
c.[415 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 §~4Ol(k),125,l32(fl(4),403(b),402(h)(,l)(B)(SEP),414(h)(2).&457.
Determination period.Compensation will be based on the following ‘determination period”(this will also be the Limitation
Year unless otherwise elected at option I under Section B of Appendix A):
d.LXI the Plan Year
e.[]the Fiscal Year coinciding with or ending within the Plan Year
f.j ]the calendar year coinciding with or ending within the Plan Year
Adjustments to Compensation (for Plan Section 1.10).Compensation will be adjusted by:
g.[J No adjustments (skip to Question 23.below)
h.[X]Adjustments.Compensation will be adjusted by (select all that apply):
1.L J excluding salary reductions (401(k),125.132(f)(4).403(b).SEP.414(h)(2)pickup,&457)
2.L 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.[excluding Compensation paid during the “determination period”while not a Participant in the Plan.
4.[X]excluding Military Differential Pay
5.[X]excluding overtime
6.[X]excluding bonuses
7.]other:__________________________(e.g..describe Compensation from 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 shift 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 extent
provided in Plan Section 1.23).post-severance regular pay,leave cash-outs and payments from nonqualified unfunded
deferred compensation plans.
a.LXI The defaults listed above apply except for the following (select one or more):
I.[]Leave cash-outs will be excluded
2.LX]Nonqualified unfunded deferred compensation will be excluded
3.IX]Disability continuation payments will be included for all Participants and the salary continuation will
continue for the following fixed or determinable period:12 months
4.L ]Other:(must be definitely determinable)
Plan Compensation (post-severance compensation adjustments)
b.[]Defaults apply.Compensation will include (to the extent provided in Plan Section 1.10 and to the extent such amounts
would 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.[]Exclude all post-severance compensation.Exclude all post-severance compensation for allocation purposes.
d.LX]Post-severance adjustments.The defaults listed at b.apply except for the following (select one or more):
I.[]Exclude all post-severance compensation
2020 Nationwide Financial Services.Inc.or its suppliers
8
EXHIBIT B
Non-Standardized Govern mental 401(a)
2.[J Regular pay will be excluded
3.[]Leave cash-outs will be excluded
4.[X]Nonqualified unfunded deferred compensation will be excluded
5.[I Military Differential Pay will be included
6.[Disability continuation payments will be included for all Participants and the salary continuation will continue
for the following fixed or determinable period:
e.(]Other:____________________(must be definitely determinable)
CONTRIBUTIONS AND ALLOCATIONS
24.EMPLOYER CONTRIBUTIONS (OTHER THAN MATCHING CONTRIBUTIONS)(Plan Section 4.I(b)(3))(skip to Question
26 if Employer contributions are NOT selected at Question I I.b.)
CONTRIBUTION FORMULA (select one or more of the following contribution formulas:)
a.[]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 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.[]Discretionary contribution (Grouping method).(may not be elected if this Plan is a 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 will not violate the definite
predetermined allocation formula requirement of Regulation §I.401-I(b$I)(ii).The Employer must notify the Trustee
in writing of the amount of the Employer Contribution being given to each group.
I.[I Each Participant constitutes a separate classification.
2.[J 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 allocating the contribution
among members of each classification.Classifications specified below must be clearly defined in a manner
that will not violate the definitely determinable allocation requirement of Regulation §I.401.I(b)(I)(ii).
Classification A will consist of
The allocation method will be:I pro rata based on Compensation
I J equal dollar amounts (per capita)
Classification B will consist of _______________________________________________
The allocation method will be []pro rata based on Compensation
I equal dollar amounts (per capita)
Classification C will consist of _______________________________________________
The allocation method will be:j ]pro rata based on Compensation
equal dollar amounts (per capita)
Classification D will consist of _______________________________________________
The allocation method will be:[]pro rata based on Compensation
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.
Determination of applicable group.If a 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 of employment.If selected below,the
Administrator will apportion the Participant’s allocation during a Plan Year based on the following:
a.I I Beginning of Plan Year.The classification will be based on the Participant’s status as of the
beginning of the Plan Year.
b.[Months in each classification.Pro rata based on the number of months the Participant spent in each
classification.
c.[]Days in each classification.Pro rata based on the number of days the Participant spent in each
classification.
d.F ]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 shift occurs.
c.[X]Fixed contribution equal to (only select one):
I.[]_______0~of each Participant’s Compensation for each:
a.[]Plan Year
b.[]calendar quarter
c.[]month
2020 Nationwide Financial Services,Inc.or its suppliers
9
EXHIBIT B
Non-Standardized Governmental 401(a)
d.[]pay period
e.[J week
2.F j $________per Participant.
3.[]$________per Hour of Service worked while an Eligible Employee
a.]up to ________hours (leave blank if no limit)
4.[X]other:See Addendum I (the formula described must satis&the definitely determinable requirement under
Regulation §1.401-1(b))NOTE:Under Question 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 thereof as to a Participant group (e.g.,a monthly contribution applies to Group A).
d.F I Sick leave/vacation leave conversion.The Employer will contribute an amount equal to an Employees current hourly
rate of pay multiplied by the Participants 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 convened under the Plan (select one or both):
I.L ]Sick leave
2.j ]Vacation leave
Eligible Employees.Only the following Participants shall receive the Employer contribution for sick leave and/or
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 for terminated Employees)
3.[]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 J The Former Employee must be at least age (e.g.,55)
b.L ]The value of the sick and or vacation leave must be at least $(e.g.,$2,000)
c.]A contribution will only be made if the total hours is over (e.g.,10)hours
d.[]A contribution will not be made for hours in excess of ...(e.g..40)hours
4.F I Active Employees.Active 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.[j The Employee must be at least age (e.g.,55)
b.F I The value of the sick and/or vacation leave must be at least $...............(e.g.,$2,000)
c.j A contribution will 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 (e.g.,40)hours
e.[]Social Security Replacement Plan.xcept as provided below,the Employer will contribute an amount equal to 7.5%
of each eligible Participant’s 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 to 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 that apply)
I.[j Part-time Employees who are not otherwise covered by another qualifying public retirement system as
defined for purposes of Regulation §31.3121 (b)(7)-2.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 1.55).
2.j j Seasonal Employees who are not otherwise covered by another qualifying public retirement system as
defined for purposes of Regulation §31.3121 (b)(7)-2.A seasonal Employee is an Employee who is
categorized as a seasonal Employee on the Employer’s payroll records.
3.F I Temporary Employees who are not otherwise covered by another qualifying public retirement system as
defined for purposes of Regulation §31.3121(b)(7)-2.A temporary Employee isan Employee who is
categorized as a temporary Employee on the Employer’s payroll records.
4.1 ]Employees in elective positions (filled by an election,which may be by legislative body.board or committee.
or by ajurisdiction’s qualified electorate)
5.j J 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 by:
a.[I the Employee only (specie’the contribution at the mandatory Employee contributions Question 30)
b.[]the Employer only
c.F ]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 °o of
each eligible Participant’s Compensation.
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
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
below do not apply to the Employer contribution made pursuant to this provision.
f.[]Other:____________________________(the formula described must satis~’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!.,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 group 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 of Plan Section 4.3 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 requirements to share in
allocations of Employer contributions (select a.OR b.and all that apply at c.-e.)
a.[X]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.[]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.L I A Participant must complete at least __________(not to exceed 500)Hours of Service if the actual
hours/equivalency method is selected (or at least ________(not to exceed 3)months of service if the elapsed
time method is selected).
2.[]A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
3.[]Participants will NOT share in the allocations,regardless of service.
4.[]Participants will share in the allocations,regardless of service.
5.[]Other (must be definitely determinable and not subject to Employer
discretion)
Conditions for Participants employed on the last day of the Plan Year
6.[]No service requirement.
7.[]A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
8.[]A Participant must complete at least _______Hours 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 Year.If b.I .2.,3..or 5.above 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 if none apply):
c.[]Death
d.[]Total and Permanent Disability
e.]Termination of employment on or after Normal Retirement Age
I.j ]or Early Retirement Date
26.EMPLOYER MATCHING CONTRIBUTIONS (Plan Section 4.1 (b)(2)and Plan Section 4.12).(skip to Question 29 if matching
contributions are NOT selected at Question II .c.)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 more):
a.j I Elective deferrals to a 457 plan.Enter Plan name(s):_______________________
b.[I 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)
13.Matching Formula.(select one)
e.]Fixed -uniform rate/amount.The Employer will make matching contributions equal to 0~(e.g..50)of the
Participant’s “matched Employee contributions”
I.L J that do not exceed %of a Participant’s Compensation (leave blank if no limit)
Additional matching contribution (choose 2.if applicable):
2.[]plus an additional matching contribution of a discretionary percentage determined by the Employer,
a.L ]but not to exceed ..............0o 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 B
Non-Standardized Governmental 401(a)
f.[]Fixed -tiered.The Employer will make matching contributions equal to a uniform percentage of each tier of each
Participant’s ‘matched Employee contributions”,determined as follows:
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
First %
Next _____%
Next _____%
Next __________%
g.j j Fixed -Years of Service.The Employer will make matching contributions equal to a uniform percentage of each
Participant’s ‘matched Employee contributions”based on the Participant’s Years of Service (or Periods of Service if the
elapsed time method is selected),determined as follows (add additional tiers if necessary):
Years (or Periods)of Service Matching Percentage
00
%
0o
For purposes of the above matching contribution formula,a Year (or Period)of Service means a Year (or Period)of
Service for:
I.[]vesting purposes
2.[I eligibility purposes
h.]Flexible Discretionary Match.(may not be elected if this Plan is a Money Purchase Pension Plan)“Flexible
Discretionary Match”means a Matching Contribution which the Employer In its sole discretion elects to make to the
Plan.Except as specified below,the Employer retains discretion over the formula or formulas for allocating the
Flexible Discretionary Match,including the Discretionary Matching Contribution 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 will receive the allocation,and the time period applicable to any
matching formula(s)(collectively,the “Flexible Discretionary Matching Formula”),except as the Employer otherwise
elects in its Adoption Agreement.Such contributions will be subject 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.B.h.I.
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.[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 allocation 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 formula 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 be 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 formulas.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 which the last “Flexible Discretionary Match”contribution is made to the Plan for the Plan Year.
[I Discretionary -tiered.(may not 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 will only pertain to the
2020 Nationwide Financial Services.Inc.or its suppliers
12
EXHIBIT B
Non-Standardized Governmental 401(a)
amount of the contribution.The tiers may be based on the rate of a Participants ‘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 $or °o)
First
Next _______
Next _______
Next _______°
F ]Other:(the formula described must satisfy the definitely determinable
requirement under Regulation §1.401-1(b)and if this is a Money Purchase Pension Plan,it must not be a discretionary
contribution formula.NOTE:Under Question 26.B.j.,the Employer may only describe the allocation of Matching
Contributions from the elections available under Question 26 and/or a combination thereof as to a Participant gmup or
contribution type (e.g.,fixed uniform rate applies to Group A;contributions to other Employees will be allocated as a
tiered contribution.)
27.MATCHING CONTRIBUTION PROVISIONS
A.Maximum matching contribution.The total matching contribution made on behalf of any Participant for any Plan Year will not
exceed:
N A (no Plan specific limit on the amount of matching contribution)
]$___
_______%of Compensation.
B.Period of determination.Any matching contribution other than a “Flexible Discretionary Match”will 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.]the Plan Year (potential annual true-up required)
e.I ]each payroll period (no true-up)
f.j ]each month (potential monthly true-up required)
g.j ]each Plan Year quarter (potential quarterly true-up required)
h.]each payroll unit (e.g.,hour)(no true-up)
i.j ]Other (specify):____________________________________The time period described must be definitely determinable
under Treas.Reg.§1.401-1(b).This line may be used to apply diflerentoptions to different matching contributions
(e.g.,Discretionary matching contributions will be allocated on a Plan Year period while fixed matching contributions
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 []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.[]A Participant must complete more than ______Hours of Service (or
time method is selected).
2.[]A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
3.1 ]Participants will NOT share in the allocations,regardless of service.
4.j j Participants will share in the allocations,regardless of service
5.[Other:_________________________________________(must be definitely determinable)
Conditions for Participants employed on the last day of the Plan Year
6.F I No service requirement.
7.F ]A Participant must complete a Year of Service (or Period of Service if the elapsed time method is selected).
8.F ]A Participant must complete at least _______Hours of Service during the Plan Year.
9.F ]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 Year.If b.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 will be eligible to
share in the allocations regardless of the above conditions (select all that apply.leave blank if none apply):
c.[I Death
d.]Total and Permanent Disability
e.I ]Termination of employment on or after Normal Retirement Age
I.F I or Early Retirement Date
0
0
0
0
a.
b.
c.
months of service if the elapsed
2020 Nationwide Financial Services,Inc.or its suppliers
13
EXHIBIT B
Non-Standardized Governmental 401(a)
Conditions based on period other than Plan Year.The allocation conditions above will be applied based on the Plan Year
unless otherwise selected below.If selected,the above provisions will be applied by substituting the term Plan Year with the
specified period (e.g.,if Plan Year quarter is selected below and the allocation condition is 250 Hours of Service per quarter,
enter 250 hours (not 1000)at b.8.above).
f.[]The Plan Year quarter.
g.[]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 1.21.a Forfeiture will occur:
a.[]N A (may only be selected if all contributions are 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 of the entire Vested portion of the 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.Forfeitures are disposed of in
accordance with Employer direction that is consistent with Section 4.3(e)).
Forfeitures will be (select one):
e.[]added to the Employer contribution and allocated in the same manner
I [X]used to reduce any Employer contribution
g.[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 Compensation of all Participants for
such year
h.I I other:_____________________________(describe the treatment of Forfeitures in a manner that is definitely
determinable and that is not subject to Employer discretion)
30.MANDATORY EMPLOYEE CONTRIBUTIONS (Plan Section 4.8)(skip if mandatory Employee contributions NOT selected
at Question 11 .d.)
Type of mandatory Employee Contribution.The mandatory Employee contribution is being made in accordance with the
following:(select one)
a.[Xi The mandatory Employee contribution is a condition of employment.
b.[J 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.
Amount of mandatory Employee Contribution (select one)
c.[X]An Eligible Employee must contribute to the Plan 8.5 ~o (not to exceed 25°o)of Compensation.
d.I I An Eligible Employee must,prior to his or her first Entry Date,make a one-time irrevocable election to contribute to
the Plan from ______0o (not less than 100)to 00 (not to exceed 25°o)of Compensation.
Conditions of Mandatory Employee Contributions
e.[J 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 l4(h)(2)
unless elected below.(select if applicable)
f.[I The mandatory Employee contribution is not “picked-up”by the Employer.
DISTRIBUTIONS
31 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.IX]lump-sums
b.[X]substantially equal installments
c.j ]partial withdrawals,provided the minimum withdrawal is $_______(leave blank if no minimum)
d.L ]partial withdrawals or installments are only permitted for Participants or Beneficiaries who must receive required
minimum distributions under Code §401(a)(9)except for the following (leave blank if no exceptions):
1.[]Only Participants (and not Beneficiaries)may elect partial withdrawals or installments
2.[]Other:(e.g..partial is not permitted for death benefits.
Must be definitely determinable and not subject to Employer discretion.)
e.[]annuity:(describe the form of annuity or annuities)
2020 Nationwide Financial Services.Inc.or its suppliers
14
EXHIBIT B
Non-Standardized Governmental 401(a)
f.[X]other:Any other sequence as reauested by 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 withdrawal of his or her total Account for an
in-service distribution,a hardship distribution,or a distribution from the Participants Rollover Account.
Cash or property.Distributions may be made in:
g.[]cash only.except for (select all that apply;leave blank if none apply):
I.[]insurance Contracts
2.[]annuity Contracts
3.[I Participant loans
4.[]all investments in an open brokerage window or similar arrangement
h.LX]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 of up to $3,000 for the direct payment of gualifyine insurance premiums for elicible
retired public safety officers are available under the Plan (must be definitely determinable and not
subject to Employer discretion)
Joint and Survivor Annuity 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 below (choose if applicable)
i.[]Joint and Survivor Annuity applicable as normal form of distribution.The Joint and Survivor annuity rules set
forth in Plan Sections 6.5(e)and 6.5(0 apply to all Participants (if selected,then annuities are a form of distribution
under the Plan even if e.above is not selected)
j.[]Joint and Sun’ivor Annuity rules apply based on Participant election.Plan Section 6.5(0 will apply and thejoint
and survivor rules of Code §*40t(a)(1 I)and 417 (as set forth in Plan Sections 6.5(e)and 6.6(e)will apply only if an
annuity form of distribution is selected by a Participant.
AND,if i.orj.is selected above,the one-year marriage rule does not apply unless selected below (choose if applicable).
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 below (choose if applicable)
k.[Required for all distributions.A Spouse must consent to all distributions (other than required minimum distributions).
I.I j 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 if applicable).
1.1 1 The one-year marriage rule applies.
32.CONDITIONS FOR DISTRIBUTIONS UPON SEVERANCE OF EMPLOYMENT.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 $5,000
a.IX]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.j ]Distributions may be made as soon as administratively feasible after the last day of the Plan Year quarter coincident
with or next following severance of employment.
d.1 ]Distributions may be made as soon as administratively feasible after the Valuation Date coincident with or next
following severance of employment.
e.[]Distributions may be made as soon as administratively feasible after months have elapsed following severance
of employment.
f.[]No distributions may be made until a Participant has reached Early or Normal Retirement Date.
g.[]Other:______________________________________(must be objective conditions which are ascertainable and may not
exceed the limits of Code §401(a)(14)as set forth in Plan Section 6.7)
B.Accounts of $5,000 or less
h.[Xi Same as above
i.[]Distributions may be made as soon as administratively feasible following severance of employment.
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.
k.[]Other:_________________________________________(must be objective conditions which are ascertainable and may not
exceed the limits of Code §40t(a)(14)as set forth in Plan Section 6.7)
C.Timing after 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 its suppliers
IS
EXHIBIT B
Non-Standardized Governmental 401(a)
was first distributable (assuming the amount is still distributable),unless otherwise selected below (may not be selected with 32.f.
and 32.h.):
I.]Other:_____________________________________(e.g.,a subsequent distribution request may only be made in
accordance with I.above (i.e.,the last day of another Plan Year);must be objective conditions which are ascertainable
and may not exceed the limits of Code §401(a)(14)asset forth in Plan Section 6.7)
Ii 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 $5,000 or less are only paid as lump-sums.
m.]No,Participant consent is required for all distributions.
n.IX]Yes,Participant consent is required only if the distribution is over:
I.[]$5,000
2.[X]$1,000
3.F ]$______(less than $1,000)
NOTE:If 2.or 3.is selected,rollovers will be included in determining the threshold for Participant consent.
Automatic IRA rollover.With respect to mandatory distributions of amounts that are $1,000 or less,if a Participant
makes no election,the amount will be distributed as a lump-sum unless selected below.
4.1 ]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).
E.Rollovers in determination of $5,000 threshold.Unless otherwise elected below,amounts attributable to rollover contributions
(if any)will be included in determining the $5,000 threshold for timing of distributions.form of distributions,or consent rules.
o.[]Exclude rollovers (rollover contributions will be excluded in determining the $5,000 threshold)
NOTE:Regardless of the above election,if 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 UPON DEATH (Plan Section 6 8(b)(2))
Distributions upon the death of a Participant prior to the “required beginning date”will:
a.IX]be made pursuant to the election of the Participant or “designated Beneficiary”
b.F I begin within I year of death for a “designated Beneficiary”and be payable over the life (or over a period not exceeding
the “life expectancy”)of such Beneficiary,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
c.F I be made within 5 (or if lesser years of death for all Beneficiaries
d.F ]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 with 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,answer a.-e.;leave blank if not applicable).
a.FXI In-service distributions may be made to a Participant who has not separated from service provided the following has
been satisfied (select one or more)(options 2.-5.may only be selected with Profit Sharing Plans):
I.LX]Age.The Participant has reached:(select one)
a.F ]Normal Retirement Age
b.F ]age62
c.F I age 59 1/2 (may not be selected if a Money Purchase Pension Plan)
d.FX]age 70 1/2 (may not be less than age 62 for Money Purchase Pension Plans)
2.F ]the Participant has been a Participant in the Plan for at least _______years (may not be less than five (5))
3 F ]the amounts being distributed have accumulated in the Plan for at least 2 years
4.F 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).)
More than one condition,If more than one condition is selected above,then a Participant only needs to satisfy one of
the conditions,unless selected below:
5.F I A Participant must satisfy each condition
NOTE:Distributions from a Transfer Account attributable to a Money Purchase Pension Plan are not permitted prior to age 62.
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
restrictions.In-service distributions are permitted from the following Participant Accounts:
all Accounts
only from the following Accounts (select one or more):
I.[I Account attributable to Employer matching contributions
2.[]Account attributable to Employer contributions other than matching contributions
3.[I Rollover Account
4.[J Transfer Account
Permitted from the following assets attributable to (select one or both):
a.[I non-pension assets
b.[I pension assets (e.g.,from a Money Purchase Pension Plan)
5.[]Mandatory Employee Contribution Account
6.[I Other:(specify Account(s)and
conditions in a manner that satisfies the definitely determinable requirement under Regulation §1.401 -1(b)
and is not subject to Employer discretion)
Limitations.The following limitations apply to in-service distributions
d.[XJ N A (no additional limitations)
e.[]Additional limitations (select one or more):
I.[]The minimum amount of a distribution is $______
2.]No more than _______distribution(s)may be made to a Participant during a Plan Year.
3.1 ]Distributions may only be made from Accounts which are fully Vested.
4.1 1 In-service 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).
B.HARDSHIP DISTRIBUTIONS (Plan Sections 6.12)(may not be selected if this is a Money Purchase Pension Plan)
Hardship 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):
f.[]Hardship distributions are permitted from the following Participant Accounts:
I.[]all Accounts
2.[]only from the following Accounts (select one or more):
a.[]Account attributable to Employer matching contributions
b.[]Account attributable to Employer contributions other than matching contributions
c.j ]Rollover Account (if not available at any time under Question 36)
d.[j Transfer Account (other than amounts attributable to a money purchase pension plan)
e.[I Mandatory Employee Contribution Account
f.[I Other (specify Account(s)and conditions in a manner
that is de initely determinable and not subject to Employer discretion)
NOTE:Hardship distributions are NOT permitted 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.[]N A (no additional limitations)
4.j ]Additional limitations (select one or more):
a []The minimum amount of a distribution is $_______
b.[]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.1 1 A Participant does not include a Fonner Employee at the time of the hardship distribution.
e.j ]Hardship distributions may be made subject to the following provisions:_______(must satisü’the
definitely determinable requirement under Regulation §1.401-1(b)and not be subject to Employer
discretion).
Beneficiary Hardship.Hardship distributions for Beneficiary expenses are NOT allowed unless otherwise selected
below.
5.[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.I I effective as of ____________________________________________
b I I eliminated effective as of ____________________________
Account
b.[]
c.[I
2020 Nationwide Financial Services.Inc.or its suppliers
EXHIBIT B
Non-Standardized Governmental 401(a)
MISCELLANEOUS
35.LOANS TO PARTICIPANTS (Plan Section 7.4)
a.[I New loans are NOT permitted.
b.[X]New loans are permitted.
NOTE:Regardless of whether new loans are permitted.if the Plan permits rollovers and/or plan-to-plan transfers,then the
Administrator 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 II .f.)
Eligibility.Rollovers may be accepted from all Participants who are Employees as well as the following
(select all that apply;leave blank if not applicable):
a.[X]Any Eligible Employee,even prior to meeting eligibility conditions to be a Participant
b.[]Participants who are Former Employees
Distributions.When may distributions be made from a Participants Rollover Account?
c.[XI At any time
d [I Only when the Participant is otherwise entitled to any distribution under the Plan
37.HEART ACT (Plan Section 4.11)(select one or more)
a.[I HEART ACT Continued benefit accruals.Continued benefit accruals will apply
b.[I Distributions for deemed severance of employment.The Plan permits distributions for deemed severance of
employment.
2020 Nationwide Financial Services,Inc.or its suppliers
EXHIBIT B
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 Letter.An adopting Employer may rely on the Provider’s IRS Opinion Letter only 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.2017-41 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 §4 l5(l)(2))in addition to this
Plan may not rely on the opinion letter issued by the Internal Revenue Service with respect to the requirements ofCode~415.
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 401(a)Pre-Approved Plan
#00 I.
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 ror 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 Execution Pages and amended pages.(Note.The Effective Dale may be retroactive or may
be prospective.)
The Provider.Nationwide Financial Services,Inc.will noti&the Employer of any amendment to this Pre-approved Plan or of any
abandonment or discontinuance by the Provider of its maintenance of this Pre-approved Plan.In addition,this Plan is provided to the
Employer either in connection with investment in a product or pursuant to a contractor other arrangement for products and/or services.
pan cessation of such investment in a product or cessation of such contractor 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 Pre-approved Plan,the Provider’s intended meaning olany Plan
provisions or the effect of the Opinion Letter issued to the Provider,please contact the Provider or the Provider’s representative.
Pmvider Name:Nationwide Retirement Solutions
Address:P.O.Box 182797
Columbus Ohio 43218
Telephone Number:(877)496-1630
Email address (optional):
The Employer,by executing below,hereby adopts this Plan (add additional signature lines as needed).NOTE:If more than one Plan type is
adopted,the Plan Provider must provide multiple plan documents for Employer signature.
EMPLOYER:City of Fort Collins
By:
DATE SIGNED
2020 Nationwide Financial Services,Inc or its suppliers
EXHIBIT B
APPENDIX A
SPECIAL EFFECTIVE DATES AND OTHER PERMITI’ED ELECTIONS
A.Special effective dates (leave blank if not applicable):
a.[]Special effective date(s):_____________________________________________.For periods prior to the specified special
effective date(s),the 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 of a Plan provision beyond
the permissible effective date under any applicable law.(The Employer has reliance on the IRS Opinion Letter only if
the features described in the preceding sentence constitute protected benefits within the meaning of Code Section
41 l(d)(6)and the regulations thereunder,and only if such 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.[]No other permitted elections
The following elections apply (select one or more):
b.j }Deemed 125 compensation (Plan Section I 23)Deemed 125 compensation will be included in Compensation and 415
Compensation.
c.jX]Break-in-Service Rules.The following Break-in-Service rules apply to the Plan.(select 1.or 2.)
I.[I Reemployed after five(S)I-Year Breaks in Service (“rule of parity”provisions)(Plan Section 3.5(e)).
The “rule of parity provisions in Plan Section 3.5(d)will apply for (select one or both):
a.I ]eligibility purposes
b.j ]vesting purposes
2.[X]Break-in-Service rules for rehired Employees.The following Break-in-Service rules set forth in Plan
Sections 3.2 and 3.5 apply:(select one or both)
a.[X]all Break-in-Service rules set forth in such Sections.
b.[]only the following:(specify which provisions apply to the Plan)
d.[X]Beneficiary if no beneficiary elected by Participant (Plan Section 6.2(f)).In the event no valid designation of
Beneficiary exists,then in lieu of the order set forth in Plan Section 6.2(f),the following order ofpriority will be used:
I.)Surviving Spouse 2.)Participants Estate.?Beneficiary?means the person (or entity)to whom all or a portion of a
deceased Participant’s interest in the Plan is payable.subiect to the restrictions of Sections 6.2 and 6.6.Upon death,the
Participant?s survivin2 spouse is the Beneficiary unless he or she consents to the Parlicipant?s naminc another
Beneficiary.(specify an order ol’beneficiaries;e.g.,children per stirpes.parents,and then step-children).
e.[]Joint and Survivor Annuity/Pre-Retirement Survivor Annuity.If the Plan applies the Joint and Survivor Annuity
rules,then the normal form of annuity will be ajoint and SO°o survivor annuity (i.e.,if3l.i.or 3t.j.is selected)and the
Pre-Retirement Survivor Annuity will be equal to 5O°o of a Participant’s interest in the Plan unless selected below
(select I.and/or 2.)
I.[]Normal form of annuity.Instead ofajoint and 50%survivor annuity,the normal form of the qualified Joint
and Survivor Annuity will be:(select one)
a.[I joint and 100%survivor annuity
b.[I joint and 75%survivor annuity
c.[j joint and 66 2)3%survivor annuity
2.[I Pre-Retirement Survivor Annuity.The Pit-Retirement Survivor Annuity (minimum Spouse’s death
benefit)will be equal to 50%of a Participant’s interest in the Plan unless a different percentage is selected
below:(select one)
a.j ]100%of a Participant’s interest in the Plan.
b.[]%(may not be less than 50°o)of a Participant’s interest in the Plan.
[]Limitation Year (Plan Section 1.30).The Limitation Year for Code §415 purposes will be _____________(must be
a consecutive twelve month period)instead of the “determination period”for Compensation.
g.[]415 Limits when 2 defined contribution plans are maintained (Plan Section 4.4).If any Participant 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 §419(e).or an individual medical
account,as defined in Code §41 5(l)(2),under which 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 otherwise 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”:
h.[I Recognition of Service with other employers (Plan Sections 1.40 and 1.55).Service with the following employers (in
addition to those specified at Question 15)will be recognized as follows (select one or more):
EXHIBIT B
Contribution
Eligibility Vesting Allocation
[]Employer name:a.[]b.I ]c.
2.[]Employer name:a.[]b.[]c.
3.[]Employer name:a.[]b.I ]c.[
4 1 ]Employername:a.[]b.L I c.[]
5 []Employername:a.[]b.[]c.[]
6.[I Employer name:a.I ]b.[I c.
Limitations
7.[]The following provisions or limitations apply with respect to the a.[]b.[I c.I I
recognition of prior service:____________________________________
(e.g.,credit service with X only on/following 1119)
[]Other vesting provisions.The following vesting provisions apply to the Plan (select one or more):
I.[Special vesting provisions.The following special provisions apply to the vesting provisions of the Plan:
__________________(must be definitely determinable and satisfy the parameters set forth at Question 17)
2.[]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
following provisions apply (must select one of a.dj:
Applicable Participants.The vesting schedules in Question 17 only apply to:
a.[]Participants who are Employees as of _____________________(enter date).
b.[]Participants in the Plan who have an I-Jour of Service on or after (enter
date).
c.[]Participants (even if not an Employee)in the Plan on or after (enter date).
d.j ]Other:_________________________(e.g..Participants in division A.Must be definitely
determinable.)
j.I I Minimum distribution transitional rules (Plan Section 6.8(e)(5))
NOTE:This Section does not apply to (I)a new 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 the amendments made by the Small Business
Job Protection Act of 1996 (SBJPA).or (3)a Plan where the transition rules below do not affect any current
Participants.
The ‘required beginning date for a Participant is:
1.j ]April 1st of the calendar year following the year in which the Participant attains age 70 1/2.(pre-SBJPA rules
continue to apply)
2.j ]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 the following exceptions (select one or both;leave blank if both applied
effective as of January I,1996):
a.[j 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 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 I N A (annuity distributions are not permitted)
2 []Upon the recommencement of distributions.the original Annuity Starting Date will be
retained
3 []Upon the recommencement of distributions,a new Annuity Starting Date is created.
b.I I 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 t/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 (1)December
31.1998,or (2)the adoption date of the restatement to bring the Plan into compliance
with the SBJPA.
k.[]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:
EXHIBIT B
2.[]Automatic revocation of spousal designation (Plan Section 6.2(g)).The automatic revocation of a spousal
Beneficiary designation in the case of divorce does not apply.
3.[j 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.
L J Applicable law.Instead of using the applicable laws set forth in Plan Section 9.4(a),the Plan will be governed by the
laws of:
m.[X]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 degree that,as determined by the Employer,a
participant is unable because of such impairment to perform any substantial gainful activity for which he/she is suited
by virtue of his/her experience.training.or education and that has lasted,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 degree of such
impairment shall be supported by medical evidence.If the Emolover maintains a long-term disability plan,the
definition of Total and Permanent Disability shall be the same as the definition of disability in the long-term disability
~(must be definitely determinable).
n.[]Inclusion of Reclassified Employees (Plan Section 1.17(a)).The Employer does not exclude Reclassified Employees
subject to the following provisions:(leave blank if not applicable):
o []Claims procedures (Plan Section 2.10).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 2.10(c)-(g)apply as follows:__________________________
(specify which provisions apply and or modified)
p.[]Age 62 In-Service Distributions For Transferred 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 if in-service distributions
are already permitted for Transferred Accounts at Question 34)
Limitations.The following limitations apply to these in-service distributions:
I.[]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.
2.1 N A (no limitations)
3.[]The following elections 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 $1,000).
b.[]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.[]In-service distributions may be made subject to the following provisions.(must be definitely
determinable and not subject to discretion).
q.j j QLACs.(Plan Section 6.8(e)(4)A Participant may elect a QLAC (as defined in Plan Section 6.8(e)(4))or any
alternative form of annuity permitted pursuant to a QLAC in which the Participant’s Account has been invested,
EXHIBIT B
ADMINISTRATIVE PROCEDURES
The following are optional administrative provisions.The Administrator may implement procedures that override any elections in this
Section without a formal Plan amendment.In addition,modifications to these procedures will not affect an Employers reliance on the Plan.
A.Loan Limitations.(complete only if loans to Participants are permitted:leave blank if none apply)
a.IX]Limitations (select one or more):
I.[Xi Loans will be treated as Participant directed investments.
2.[]Loans will only be made for hardship or financial necessity as specified below (select a.orb)
a.[j hardship reasons specified in Plan Section 6.12
b.[j financial necessity (as defined in the loan program).
3.[Xl The minimum loan will be $1.000
4.[X]A Participant may only have one (I)(e.g.,one (I))loan(s)outstanding at any time.
5.[I 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.[]The home loan term will be years.(if not selected,the Administrator establishes the term for repayment of
a home loan)
7 []Account restrictions.Loans will only be permitted from the following Participant Accounts (select all that apply
or leave blank if no limitations apply):
a.I ]Account(s)attributable to Employer matching contributions
b.[]Account attributable to Employer contributions other than matching contributions
c.[]Rollover Account
d.j ]Transfer Account
e.I ]Other:__________________________________________________
AND,if loans are restricted to certain accounts,the limitations of Code §72(p)will be applied:
f.[]by determining the limits by only considering the restricted accounts.
g []by 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 [X]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.[I payroll deduction
2.[X]ACH (Automated Clearing House)
3.[]check
a.I ]Only for prepayment
c.[X]Interest rate.Loans will be granted at the following interest rate (if left blank,then 3 below applies):
I.[Xj .5 percentage points over the prime interest rate
2.1 1 ______
3.[I the Administrator establishes the rate at the time the loan is made
d.IX]Refinancing.Loan refinancing is allowed.
B.Life Insurance.(Plan Section 7.5)
a.IX]Life insurance may not be purchased.
b.I ]Life insurance may be purchased...
I.[j at the option of the Administrator
2 []at the option of the Participant
Limitations
3.[]N A (no limitations)
4.[]The purchase of initial or additional life insurance will be subject to the following limitations (select one or more):
a.I ]Each initial Contract will have a minimum face amount of$
b.]Each additional Contract will have a minimum face amount of$
c.[]The Participant has completed .Years (or Periods)of Service.
d.I 1 The Participant has completed _______Years (or Periods)of Service while a Participant in the Plan.
e.[]The Participant is under age _______on the Contract issue date.
f.[]The maximum amount of all Contracts on behalf of a Participant may not exceed $
g.[I The maximum face amount of any life insurance Contract will be $_______
C.Plan Expenses.Will the Plan assess against an individual Participants Account certain Plan expenses that are incurred by.or are
attributable to.a particular Participant based on use of a particular Plan service?
a.[]No
b.[X]Yes
EXHIBIT B
Use of Forfeitures
Forfeitures of Employer contributions other than matching contributions will be:
c.[]added to the Employer contribution and allocated in the same manner
d.[]used to reduce any Employer contribution
e.[]allocated to all Participants eligible to share in the allocations of Employer contributions or Forfeitures in the same
proportion that each Participants Compensation for the Plan Year bears to the Compensation of all Participants for such year
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:
g.]N A.Same as above or no Employer matching contributions
h.[]used to reduce the Employer matching contribution.
i.j ]used to reduce any Employer contribution.
j.[]other:____________________________________(describe the treatment of Forfeitures in a manner that is definitely
determinable and not subject to Employer discretion)
D Directed investments
a.[]Participant directed investments are NOT permitted.
b.[X]Participant directed investments are permitted from the following Participant Accounts:
X]all Accounts
2.1 ]only from the following Accounts (select one or more):
a.[]Account attributable to Employer contributions
b.[I Rollover Account
c.[I Transfer Account
d.[j Other:_____________________________________(specify Account(s)and conditions in a manner that is
definitely determinable and not subject to Employer discretion)
F.Rollover limitations.Will the Plan accept rollover contributions and/or direct rollovers from the sources specified below9
a.[j No.Administrator determines in operation which sources will be accepted.
b.[X]Yes
Rollover sources.Indicate the sources of rollovers that will be accepted (select one or more)
t.[XI Direct Rollovers.The Plan will accept a direct rollover of an eligible rollover distribution from (select one or
more):
a.[]a qualified plan described in Code §40t(a)(including a 40 1(k)plan,profit sharing plan,defined benefit
plan.stock bonus plan and money purchase plan),excluding after-tax employee contributions
b.jX]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.j ]a plan described in Code §403(a)(an annuity plan),excluding after-tax employee contributions
d.[X]a plan described in Code §403(a)(an annuity plan),including after-tax employee contributions
e []a plan described in Code §403(b)(a tax-sheltered annuity).excluding after-tax employee contributions
f [X]a plan described in Code §403(b)(a tax-sheltered annuity),including after-tax employee contributions
g.[XJ a plan described in Code §457(b)(eligible deferred compensation plan)
Direct Rollovers of Participant Loan.The Plan witl NOT accept a direct rollover of a Participant loan from
another plan unless selected below (leave blank if default applies)
h.I ]The Plan will accept a direct rollover of a Participant loan
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.[XI 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.[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)
b.LX]a plan described in Code §403(a)(an annuity plan)
c.LX]a plan described in Code §403(b)(a tax-sheltered annuity)
d.[X]a governmental plan described in Code §457(b)(eligible deferred compensation plan)
3.[X]Participant Rollover Contributions from IRAs:The Plan will accept a rollover contribution of the portion of 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 lRAs.A rollover from a SIMPLE IRA is allowed 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.[]Do not produce the trust agreement
b.[Xi Complete the following UNLESS not selecting supporting forms:
EXHIBIT B
Trustee/Insurer (select a OR one or more of a’.-e.)
c.[]Insurer.This Plan is funded exclusively with Contracts (select one or more of 1.-4)
Name of Insurer(s)
I.[]_______________
2.[]__________
3.[]Use Employer address/telephone number/email
4.[]Use following address/telephone number/email
a.Street:_________________________________
b City:
c.State:__________________________________
d.Zip:
e.Telephone:
f.Email:______________________________
d.[]Individual Trustee(s)
e.[X]Corporate Trustee
Name of Trust
f.Specify name of Trust (required for FIS trust):City of Fort Collins Police Plan
Individual Trustees (if d.selected above,complete g.—j.)
Directed/Discretionary Trustees.The individual Trustee(s)executing this Adoption Agreement are (select g.or h.)
g.[]Select for each individual Trustee (skip to next question)
h.L ]The following selections apply to all individual Trustee(s)(select I.-4.as applicable)
I.[I A discretionary Trustee over all plan assets (may not be selected with 2.-4.)
2.[]A nondiscretionary (directed)Trustee over all plan assets (may not be selected with I.,3.or 4.)
3.[]The individual Trustee(s)will serve as a discretionary Trustee over the following assets:
(may not be selected with I.or 2.)
4.[j The individual Trustee(s)will serve as a nondiscretionary (directed)Trustee over the following assets:
______________(may not be selected with 1.or 2.)
Individual Trustee(s)(complete if d.selected above)
Individual Trustee(s)are (select one or more of a.-j.;enter address atj.below)
a.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.j ]A discretionary Trustee over the following plan assets:_____________(may not be select with 3.or 5.)
5.j Nondiscrettonary Trustee over all plan assets (may not be selected with 3.,4.or 6.)
6.j I A nondiscretionary (directed)Trustee or Custodian over the following plan assets (may not be
selected with 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.]Discretionary Trustee over all plan assets (may not be selected with 4.6.)
4.[]A discretionary Trustee over the following plan assets:(may not be select 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 ___________(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.[]A discretionary Trustee over the following plan assets:___________(may not be select with 3.or 5.)
5.L ]Nondiscretionary Trustee over all plan assets (may not be selected with 3.,4.or 6.)
6.[j A nondiscretionary (directed)Trustee or Custodiaa over the following plan assets (may not be
selected with 3.or 5.)
EXHIBIT B
d.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.L I A discretionary Trustee over the following plan assets:___________(may not be selected with 3.or 5.)
5.L J Nondiscretionary Trustee over all plan assets (may not be selected with 3.,4.or 6.)
6.L J A nondiscretionary (directed)Trustee or Custodian over the following plan assets ________________(may
not be selected with 3.or 5.)
e.Name __________
Title/Email:
I.Title ___________
2.Email ___________(optional)
Trustee is:(complete if g.selected above;select 3.—6.as applicable)
3.[]Discretionary Trustee over all plan assets (may not be selected with 4.or 6.)
4.L ]A discretionary Trustee over the following plan assets:___________(may not be selected with 3.or 5.)
5.j ]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 ___________(may not be
selected with 3.or 5.)
f.Name_______
Title/Email:
I.Title __________
2.Email ___________(optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3.[]Discretionary Trustee over all plan assets (may 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.[]Nondiscretionary Trustee over all plan assets (may not be selected with 3.,4.or 6.)
6.1 1 A nondiscretionary (directed)Trustee or Custodian over the following plan assets ___________(may not be
selected with 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.[]Discretionary Trustee over all plan assets (may 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.[]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 (may 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.[]Discretionary Trustee over all plan assets (may 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.[]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 ___________(may not be
selected with 3.or 5.)
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.or 6.)
4 [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 (may not be
selected with 3.or 5.)
EXHIBIT B
j.Name _______
Title/Email:
I.Title _________
2.Email ___________(optional)
Trustee is:(complete if g.selected above:select 3.6.as applicable)
3.j J Discretionary Trustee over all plan assets (may not be selected with 4.or 6.)
4.j A discretionary Trustee over the following plan assets:___________(may not be selected with 3.or 5.)
5 1 1 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 (may not be
selected with 3.or 5.)
j.[]Individual Trustee Address (complete if d.selected above)
I.[]Use Employer address/telephone number email
2.j ]Use following address/telephone number email
a.Street:_____________
b.City:
c.State:___________
d.Zip:__________
e Telephone:
f.Email:___________
Corporate Trustee Name/Type/Address (complete if e.selected above)
k.[Xi Name Nationwide Trust Company.FSB
Address/telephone number/email
I.[]Use Employer address/telephone number email
2,[X]Use following address/telephone number email
a.Street:10 West Nationwide Blvd.
b.City:Columbus
c.State:Ohio
d.Zip:43215
e.Telephone:(614)435-5633
f.Email:_________
Directed/Discretionary.The Corporate Trustee is (select 3.-6.as applicable)
3.[]A discretionary Trustee over all plan assets (may not be selected with 4.6.)
4.[X]A nondiscretionary (directed)Trustee over all plan assets (may not be selected with 3..5.or 6.)
5.[I A discretionary Trustee over the following plan assets over the following assets:________(may not be
selected with 3.4.)
6.[]A nondiscretionary (directed)Trustee over the following plan assets ________(may not be selected with 3
4.)
Signee (optional):
7.[]Name of person signing on behalf of the corporate Trustee ___________
8.1 1 Email address olperson signing on behalfof the corporate Trustee
Special Trustee for collection of contributions.The Employer appoints the following Special Trustee with the responsibility to
collect delinquent contributions (optional)
[XJ Name Blame Dunn
Title:
1.Accountinp Director
Address/telephone number/email
2.[]Use Employer address/telephone number/email
3.IX]Use following address/telephone number/email
a.Street:2)5 N Mason St
b.City:Fort Collins
c.State:Colorado
d.Zip:80524
e.Telephone:970-221-6784
f.Email:bdunn(~fcgov.com
Custodian(s)Name/Address .The Custodian(s)are (optional)
m.j ]Name(s)___________
Address/telephone number/email
I []Use Employer address/telephone number email
EXHIBIT B
2.[]Use following address/telephone number email
a.Street:_____________
b.City:________
c.State:_____________
d.Zip:__________
e.Telephone:
C Email:
Investment in common,collective or pooled trust funds.The nondiscretionary Trustee,as directed or the discretionary Trustee
acting without direction (and in addition to the discretionary Trustee’s authority to invest in its own funds),may invest in any of
the following trust funds:(optional)
n.[](Specify the names of one or more trust funds in which the Plan can invest)
Choice of law
o.[X]This trust will be governed by the laws of the state oI~
I.[]State in which the Employer’s principal office is located
2.[X]State in which the corporate trustee or insurer is located
3 []Other _____________________
EXHIBIT B
City of Fort CoHins Police Plan
Addendum 1
Nationwide-Sponsored Cycle 3 Governmental
The following provisions are incorporated into Question 24 of the Adoption Agreement
Section 24.c.4:Employer Contributions (other than matching contributions)-The Employer will make the
following contributions
Year(s)%Of Compensation
2019 10%
2020 10.5%
202 1-2024 11%