PART I CIRCLE SECTION

1. Does the Plan contain a medical benefits account within the meaning of § 401(h) of the Internal Revenue Code (Code)? If the medical benefits account is a new provision, items “a” through “h” Yes No ___ should be completed.

a. Does the medical benefits account specify the medical benefits that will be available and con Yes No ___ tain provisions for determining the amount that will be paid?

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

Yes No ___ key employees (as defined in § 416(i)(1)) to fund such benefits?

e. Does the medical benefits account state that amounts contributed must be reasonable and ascer Yes No ___ tainable?

f. Does the medical benefits account provide for the impossibility of diversion prior to satisfac Yes No ___ tion of liabilities (other than item “7” below)?

g. Does the medical benefits account provide for reversion upon satisfaction of all liabilities (oth Yes No ___ er than item “7” below)?

h. Does the medical benefits account provide that forfeitures must be applied as soon as possible

Yes No ___ to reduce employer contributions to fund the medical benefits?