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�� � �' <br /> � FLEXIBLE BENEFITS PI�N II <br /> • ADOPTION AGREEMENT <br /> By execution of this Adoption Agreement, the Employer identified <br /> below hereby adopts the Fort Dearborn Life Insurance Company <br /> employees ' Flexible Benefits Plan II with the elections herein <br /> set forth for its Eligible Employees. <br /> A. General <br /> l. Name and Address of Employer: City of Decatur <br /> #1 Civic Center Plaza, Decatur, IL 62523-1196 <br /> 2 . Employer ldentification Number: 36-6001308 <br /> 3 . Type of entity: Government <br /> (corporation, partnership; if a <br /> partnership, self-employed individuals <br /> may not participate and if a Subchapter <br /> S corporation, 2. 0% shareholder - <br /> employees ,may not participate, etc. ) <br /> 4 . Effective Date: Januarv 1, 1992 <br /> (If none stated, the Effective Date <br /> will be the first day of the Calendar <br /> Year beginning after the date of <br /> execution of the Adoption Agreement. ) <br /> 5. Name of Plan: Citv of Decatur <br /> Flexible Benefits Plan <br /> 6. Plan Year: Calendar <br /> (If none stated, the Plan Year will be the <br /> calendar year. ) <br /> B. Benefits and Contributions <br /> Yes No <br /> 1. Basic Plans <br /> a. Flexible Spending Account <br /> i. Medical and Dental Plan X <br /> ii. Dependent Care Plan X <br /> FSA-30-290 <br /> � 1 <br />