PART I

CIRCLE SECTION

1. Does the Plan contain a medical benefits account within the meaning of § 401(h) of the Code? If the medical benefits account is a new provision, items “a” through “h” should be completed.

a. Does the medical benefits account specify the medical benefits that will be available and contain provisions for determining the amount which will be paid?

Yes No

Yes No

b. Does the medical benefits account specify who will benefit? Yes No

c. Does the medical benefits account indicate that such benefits, when added to any life insurance protection in the Plan, will be subordinate to retirement benefits? (This requirement will not be satisfied unless the amount of actual contributions to provide § 401(h) benefits (when added to actual contributions for life insurance protection under the Plan) does not exceed 25 percent of the total actual contributions to the Plan (other than contributions to fund past service credits), determined on an aggregate basis since the inception of the § 401(h) arrangement.)

d. Does the medical benefits account maintain separate accounts with respect to contributions to key employees (as defined in § 416(i)(1) of the Code) to fund such benefits?

e. Does the medical benefits account state that amounts contributed must be reasonable and ascertainable?

f. Does the medical benefits account provide for the impossibility of diversion prior to satisfaction of liabilities (other than item “7” below)?

g. Does the medical benefits account provide for reversion upon satisfaction of all liabilities (other than item “7” below)?

h. Does the medical benefits account provide that forfeitures must be applied as soon as possible to reduce employer contributions to fund the medical benefits?