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. Yes No ___

a. Does the medical benefits account specify the medical benefits that will be

available and contain provisions for determining the amount that will be paid? 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.) Yes No ___

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? Yes No ___

e. Does the medical benefits account state that amounts contributed must be

reasonable and ascertainable? Yes No ___

f. Does the medical benefits account provide for the impossibility of diversion prior

to satisfaction of liabilities (other than item “7” below)? Yes No ___

g. Does the medical benefits account provide for reversion upon satisfaction of all

liabilities (other than item “7” below)? Yes No ___

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? Yes No ___