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Proposal - Empower - 2023-10-31
PROPOSAL Costa Mesa Sanitary District 457(b) plan October 31, 2023 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Proposal For Costa Mesa Sanitary District 457(b) plan This proposal valid until:1/31/2024 This Proposal was provided at the request of the plan sponsor or the Plan’s advisor on behalf of the plan. The fee information provided in this Proposal is based on the assumptions and/or investment options reflected in the Proposal. This Proposal is invalid if the assumptions and/or investment options are inaccurate or change. Plan Assumptions October 31, 2023 Plan Assets:$1,281,462 Annual Contribution:$167,000 Plan Participants with a Balance:27 Total Eligible Employees:27 Number of Plans:1 Investment Platform:Custom NAV Investment Fiduciary:Envestnet 3(38) Mapping Strategy:Like Funds Default Fund:Target Date PEA:0.05% Annually Empower Retirement Plan Document Required Fee Summary Fee Paid By Annual Plan Maintenance (Per Plan)$0 Employer Annual Participant Account Maintenance $0 Employer Asset Based Fee 0.30%Participant Installation Fee Waived Employer Weighted Average Net Investment Expense 0.26%Participant Additional Plan Services Trustee/Custodial Services: Great-West Trust Trustee & Full Custodian BEL Restoration: N/A Compliance Services: N/A Manual Payroll: N Auto Enroll: N Prospectus Fulfillment: N Fee Levelization: Y Additional Education Days: 1 Addt'l Participant Notice Delivery: N For Home Office Use Only Costa Mesa Sanitary District 457(b) plan Version Group Account Number:State Situs:Product Code:Quote Date:RSD Name:Prepared by:401(k) Version: CA gvmt-401k 10/31/2023 8:50:07 AM Whipple chrgld V16.6 10/11/2023 6:00:00 AM 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 2 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Plan and Participant Fees Plan Service Fees Fee Type Fee Paid By Asset Based Fee 0.30% Annually on All Assets Deducted from Participant Accounts Quarterly Participant Account Maintenance $0 Per Account Annually Billed to Plan Sponsor Quarterly Plan Maintenance $0 Annually Per Plan Billed to Plan Sponsor Quarterly Annual asset based fees will be calculated based upon an average daily balance. Participant Transaction Fees Transaction fee type Fee Paid by Loan initiation $95 per request Netted From Distribution Maintenance fee for NEW loans (recurring)$50 annually Deducted from participant accounts quarterly Withdrawals (including Separation of Service, Retirement, Plan Terminations)$75 per request Netted from withdrawal Withdrawals for small balance force-outs (deminimus)$25 per request Netted from distribution Distributions (including In-Service, Hardship, QDRO, Death, Disability)$50 per request Netted from distribution Express delivery fee $40 per request Netted from distribution Hardship qualification approval services $75 per request Netted from distribution or participant account Beneficiary distribution approval services $75 per request Netted from distribution QDRO approval services $400 per request Netted from distribution Periodic payment setup $50 per request Deducted from participant accounts Periodic payment maintenance $25 annually Deducted from participant accounts quarterly The above recordkeeping fees will be guaranteed for the initial five (5) year contract term from the Effective Date of the Administrative Services Agreement. Material changes (+/- 10%) from assumptions used in pricing (participants, assets, net flow, asset allocations) could void this guarantee. The Participant Transaction services above will be provided to the Plan unless the plan sponsor elects otherwise. 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 3 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Fund Information Revenue Sharing Included In Gross/Net Expense Ratio Investment Name Ticker Gross/Net Expense Ratio 12B-1 Admin Assets Allspring Core Plus Bond R6 STYJX 0.47/0.30%0.00%0.00% $8,357 American Century Global Real Estate R6 ARYDX 0.77/0.77%0.00%0.00% $0 American Century Mid Cap Value Fund (IS Platform)N/A 0.55/0.55%0.00%0.00% $2,542 American Funds New World R6 RNWGX 0.57/0.57%0.00%0.00% $11,295 BlackRock High Yield Bond K BRHYX 0.51/0.51%0.00%0.00% $40,477 DFA Diversified Fixed Income Instl DFXIX 0.26/0.15%0.00%0.00% $20,568 Fidelity® 500 Index FXAIX 0.02/0.02%0.00%0.00% $181,362 Fidelity® International Index FSPSX 0.04/0.04%0.00%0.00% $0 Fidelity® Mid Cap Index FSMDX 0.03/0.03%0.00%0.00% $0 Fidelity® Small Cap Index FSSNX 0.03/0.03%0.00%0.00% $24,169 Fidelity® US Bond Index FXNAX 0.03/0.03%0.00%0.00% $0 Franklin Rising Dividends R6 FRISX 0.52/0.52%0.00%0.00% $81,779 GG Trust American Funds 2010 Fund CL I N/A 0.20/0.20%0.00%0.00% $173,683 GG Trust American Funds 2015 Fund CL I N/A 0.22/0.22%0.00%0.00% $170 GG Trust American Funds 2020 Fund CL I N/A 0.24/0.24%0.00%0.00% $91,407 GG Trust American Funds 2025 Fund CL I N/A 0.26/0.26%0.00%0.00% $31,107 GG Trust American Funds 2030 Fund CL I N/A 0.29/0.29%0.00%0.00% $202,286 GG Trust American Funds 2035 Fund CL I N/A 0.34/0.34%0.00%0.00% $3,218 GG Trust American Funds 2040 Fund CL I N/A 0.39/0.39%0.00%0.00% $29 GG Trust American Funds 2045 Fund CL I N/A 0.41/0.41%0.00%0.00% $6,661 GG Trust American Funds 2050 Fund CL I N/A 0.41/0.41%0.00%0.00% $52,988 GG Trust American Funds 2055 Fund CL I N/A 0.42/0.42%0.00%0.00% $50,862 GG Trust American Funds 2060 Fund CL I N/A 0.42/0.42%0.00%0.00% $0 GG Trust American Funds 2065 Fund CL I N/A 0.42/0.42%0.00%0.00% $0 Hartford World Bond R6 HWDVX 0.62/0.62%0.00%0.00% $0 Janus Henderson Enterprise N JDMNX 0.66/0.66%0.00%0.00% $4,513 Large Cap Growth / JPMorgan Investment Management Fund N/A 0.41/0.41%0.00%0.00% $34,853 Lord Abbett International Equity R6 LICVX 0.63/0.63%0.00%0.00% $68,115 MFS Value R6 MEIKX 0.44/0.43%0.00%0.00% $4,293 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 4 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Fund Information Continued Revenue Sharing Included In Gross/Net Expense Ratio Investment Name Ticker Gross/Net Expense Ratio 12B-1 Admin Assets PIMCO RAE US Small Instl PMJIX 0.51/0.50%0.00%0.00% $0 PRIAC GIF N/A 0.00/0.00%0.00%0.00% $151,007 State St US Infl Protct Bnd Idx SL Cl II N/A 0.04/0.04%0.00%0.00% $12,309 Virtus SGA International Growth R6 SCIZX 1.24/0.95%0.00%0.00% $23,412 Average Net Expense Ratio 0.26% Not all 12b-1 and Admin fees may flow through the Recordkeeper. A third party may be receiving 12b-1 and/or Admin fee(s) directly that are not reflected above. 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 5 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Payments to Others Financial Professional Services (Included in Plan Pricing) Service Provider Service Fee None Other Services (Included in Plan Pricing) Service Provider Service Service Type Fee Costa Mesa Sanitary District 457(b) plan Plan Expense Account Investment Fiduciary Services 0.05% Annually A portion of fees may be credited to a Plan Expense Account (PEA) on a monthly basis to be used to pay plan expenses. The plan sponsor is responsible for determining the appropriate use of amounts credited to the PEA and for directing Empower as to the payment of any plan expenses from the PEA. The above plan fees to be paid from PEA credits is based on information provided to Empower by the plan sponsor or its advisors and is subject to plan sponsor direction. Asset based PEA payments will be calculated based upon an average daily balance. The Plan Sponsor is solely responsible for determining the allocation of any PEA credits remanining after expenses are paid. The Revenue Credits are funded from Empower's general assets and are being made available as a reduction in the compensation that Empower would otherwise earn in connection with the services it provides to the Plan. No specific funds will be set aside in an account or fund for the Plan's benefit or otherwise segregated for purposes of funding the Revenue Credits, and the Plan has no right, title or interest in any Revenue Credits prior to the time the Revenue Credit is paid to the Plan. No interest will be earned by the Plan or paid on Revenue Credits that are accrued. Empower will pay Revenue Credits to the Plan on a monthly basis. Revenue Credits shall be determined by multiplying the average daily balance in each of the Plan's investment options for the month by the annual rate (prorated for the month) of fund service fees paid to Empower by the investment option or its affiliates as reflected in the Plan's Plan Fee Disclosure Report (A copy of the Plan's most recent Fee Disclosure Report is available on the Plan Sponsor Website). Plan Sponsor directs Empower to allocate any Revenue Credits to Plan Participant accounts proportionately based on the average daily balance of such accounts in the investment option during the month and to invest such amounts based on the Participant's investment elections with respect to future contributions or, if none, the applicable Plan default fund. Revenue Credits shall be determined and allocated within 45 days after the end of the month. Trustee/Custodial Services (Included in Plan Pricing) Service Provider Service Fee Great-West Trust Company Trustee & Full Custodian $750 Annually 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 6 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Participant Advice Opt-In Service Provider Service Annual Fee Basis Advised Assets Group, LLC.Online Investment Guidance No Charge N/A Advised Assets Group, LLC.Online Investment Advice $0 Per Participant Advised Assets Group My Total Retirement Services 0.65% <$100k 0.55% Next $150k 0.45% Next $150k 0.35% >$400k My Total Retirement Assets Online Investment Advice and Managed Accounts services are optional services that are offered by Advised Assets Group, LLC. Each individual participant may elect to enroll in either one of these services. These participant advice fees are only deducted from participant account balances of those that have enrolled in the service. Plan Sponsor agrees the managed account service fee will be paid for by a Plan Participant unless the following box is selected. gfedc Plan Sponsor Pay 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 7 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Disclosures This document contains estimates of plan expenses and is intended to provide a detailed summary of fees being charged to the plan or its participants to the extent such information is in the Recordkeeper’s possession. While it is intended to provide information regarding all material fees, this document may not be comprehensive, and it may not include full information on fees associated with some specially negotiated services or with certain investment options, such as Self-Directed Brokerage Accounts, Life Insurance, Employer Stock, etc. For further fee information, please refer to the relevant service agreements and/or prospectuses, including information that may be needed to comply with Participant Disclosure obligations. As your Recordkeeper, we make no representation as to the completeness or accuracy of materials, such as prospectuses, created and/or provided by a third-party investment provider. General Bank Credit Disclosure: Empower Retirement™ (Empower), or one of its affiliates, may earn credits and/or interest on Plan assets awaiting investment or pending distribution. Any credits or interest earned by Empower are aggregated with credits and/or interest earned by Empower and will be used to defray the aggregate expenses for the maintenance of bank accounts. Empower will not retain credits and/or interest earned in excess of such maintenance expenses. Credits and/or interest are earned from the use of (i) uninvested contributions received too late in the day or not received in good order to be invested same-day and (ii) proceeds from investment option redemptions where Plan distribution checks have not been presented for payment by Plan participants. Credits and/or interest (i) begin to accrue on contributions, on the date such amounts are deposited into the bank account and end on the date such amounts are invested pursuant to Plan participant instructions and (ii) begin to accrue on distributions, on the date the check is written or on the wire date, as applicable and end on the date the check is presented for payment or when the wire clears against the account, as applicable. Earnings of credits and/or interest are at the rate the bank proivdes from time to time. Recordkeeping Costs Estimate Great-West recordkeeping fees are agreed to with the plan sponsor based on the total value of the relationship with the plan. Great- West may provide recordkeeping fee credits in its sole discretion based on criteria as solely determined by Great-West which may include the plan's use of affiliated and non-affiliated funds or products. Such credits may reduce some or all of the recordkeeping fees that would otherwise be charged by Great-West. The average cost of Great-West recordkeeping services without any reduction or offset is $120.23 per participant for plans less than $50 million, $94.42 per participant for plans between $50m and $500m and $70.13 per participant for plans greater than $500m. Prospectus Delivery: Employer agrees to accept delivery of prospectuses for the selected investment options through the Plan Sponsor section of the Empower Web site - www.empower-retirement.com. Fiduciary Disclosures Advised Assets Group (AAG): If Advised Assets Group, LLC provides services to the Plan under an agreement with Plan Sponsor, it may be a fiduciary and Registered Investment Advisor to the Plan to the extent provided in such agreement. Empower: Empower is not acting as a fiduciary for this plan 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 8 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Investments Mutual Fund Expense Ratio: The Service Provider has entered into agreements with certain funds (or their service providers including advisors, administrators or transfer agents, and underwriters) whereby the Service Provider provides shareholder and/or distribution services and receives compensation from the funds (or their service providers) based on the value of the plan's investment in the funds. This compensation may include fees for administrative and other expenses and/or fees paid under a plan of distribution under SEC Rule 12b-1 ("12b-1 fees"). The fees received by the Service Provider are included in the expense ratio described in the applicable fund’s prospectus or similar disclosure document, and reduce the fund’s net asset value (NAV). Generally, fees and expenses included in the fund’s expense ratio are deducted at regular intervals based on a percentage of the fund’s average daily net assets. Redemption Fees: Redemption fees are charged by mutual fund companies to discourage investors from making a short-term "round trip" (i.e., a purchase, typically a transfer, followed by a sale within a short period of time). Many mutual fund companies will impose the fee upon the purchase and subsequent sale occurring within a specified time frame. Please refer to your mutual fund prospectuses for specific redemption fee details. Additional Fund Compensation: Great-West Life & Annuity Insurance Company receives payments from some investment fund families through the Empowering Fund Partnership Program (“EFPP”). Under the EFPP, fund families receive several services based on the EFPP tier in which they participate. These services are provided directly to fund families and include: (i) consideration for inclusion in Empower products developed for some segments of the retirement and IRA market, (ii) inclusion on the Empower Select investment platform, which is available in the small plan recordkeeping market, (iii) a waiver of the connectivity fee described below, (iv) enhanced marketing opportunities, (v) additional reporting capabilities, (vi) collaboration in thought leadership opportunities, (vii) access to meetings with Empower leadership, Empower staff, and the third party advisory and brokerage firms through whom Empower distributes its services, and (viii) access to conferences put on by Empower and Great-West Financial. The yearly fees for EFPP participation are $1,000,000 for tier 1, $500,000 for tier 2, and $250,000 for tier 3. These fees do not vary based on an Empower client’s use of the funds offered by the fund family. For additional information about funds that participate in the fund partner program, please visit https://docs.empower- retirement.com/advisor/Empowering-Fund-Partnership-Disclosure.pdf. Great-West Life & Annuity Insurance Company also receives payments from fund families through a connectivity program (the “Connectivity Program”). The Connectivity Program charges fund families for the cost of administering funds on Empower investment platforms, and for building and maintaining data connections between Empower and the fund family. In 2019, the Connectivity Program charges $1,000 per investment fund used on recordkeeping and IRA investment platforms. Beginning in May 2019, if a retirement plan begins receiving recordkeeping services through Empower’s small plan recordkeeping segment, and the plan offers a fund from a fund family that does not participate in the Connectivity Program or the EFPP, then Empower will assess a supplemental, separate investment access fee to the plan. Depending on the level of investment in the non-participating fund family, the investment access fee charge may be more or less than the fees received under the Connectivity Program from the fund family. For additional information about funds that participate in the Connectivity Program, please visit https://docs.empower- retirement.com/advisor/Empowering-Fund-Partnership-Disclosure.pdf. 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 9 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Affiliates and Subcontractors We are required to disclose certain fees paid between Empower and its related parties (affiliates and subcontractors). This includes compensation paid in connection with the services Empower or its affiliates have agreed to provide to the plan, if the compensation is set on a transaction/incentive basis (such as commissions, soft dollars, or finder's fees) or if the compensation is charged directly against a plan investment and reflected in the investment’s net value. The fees disclosed are not in addition to previously disclosed fees; rather, this information is intended to increase transparency about how Empower uses the fees it receives. Affiliates: The following entities are affiliates of the Recordkeeper, in that they directly or indirectly control, are controlled by, or are under common control with the Recordkeeper. These affiliates may receive fees from the plan, or from the Recordkeeper or another affiliate for performing certain services for the plan. Refer to the Itemized Services and Cost section for details regarding affiliate payments. GWFS Equities, Inc. is an affiliate that receives payments from the Investment Provider. Payments are first paid to GWFS Equities, Inc. which in turn pays the Recordkeeper. Great-West Capital Management, LLC is an affiliate that receives payments from the Investment Provider. Great-West Funds, Inc. is an affiliate that receives payments from the Investment Provider. Affiliates: The following are affiliates of Empower, but not all Empower affiliates may pertain to your Plan. •Advised Assets Group, LLC •GWFS Equities, Inc. •EMJAY Corporation •FASCore, LLC •Great-West Capital Management, LLC •Great-West Funds, Inc. •Putnam Investment Company •Great-West Trust Company, LLC •Great-West Life & Annuity of New York Subcontractors: A subcontractor is any person or entity that is not an affiliate of the Recordkeeper and that is expected to receive $1,000 or more in compensation for performing one or more services for your Plan under a contract or arrangement with the Recordkeeper. All such subcontractors that receive the specific types of compensation described above are included. All such subcontractors, if any, are listed in the table below, along with the service they provide. Please refer to the Itemized Services and Cost section for details regarding subcontractor payments. Company Subcontractor Service Provided QDRO Consultants Plan administration services - QDRO review services 10/31/2023 8:50:07 AM (409427) (None) (P-F MA-MTR) Then Page 10 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Costa Mesa Sanitary District 457(b) plan (continued) Signature Page By signing this signature page, the Plan Sponsor, Broker and any other signatories certify that they have received, read and understand this proposed Fee Schedule and Disclosure Statement. All parties understand the proposal assumptions stated above determine the plan’s expenses. A change to the assumptions will cause expenses and fees to also change Plan Sponsor understands and agrees to all services and fees identified in this Fee Schedule and agrees to pay all fees according to the Service Agreement to which this Fee Schedule applies. The Plan Sponsor further understands that all payroll deduction and matching contributions will be remitted electronically using the Plan Service Center system. Contributions received using any other method will be returned unallocated for resubmission via the Plan Service Center and will not be considered plan assets until such resubmission. Plan Sponsor also understands that no payroll deduction contributions may be withheld until there is a signed Plan Document in place and no contribution or transfer of assets will be accepted earlier than 15 days from the receipt and acceptance of the Client Application in Greenwood Village, CO. The Plan Sponsor directs Empower to reflect the Advisor and Firm below as the Plan's financial advisor on its recordkeeping system and to provide plan data upon request. The Plan Sponsor understands and agrees that Empower does not provide investment advice to the Plan, the Plan Sponsor or the Advisor regarding Plan investment options. I agree any changes to products, plan services, fees, or investment options hereafter must be made post-conversion Plan Sponsor Signature:|S1|_______________________________________________________________ Print Name:|N1|_______________________________________________________________ Date:|D|_____________________________________ Advisor/Broker Signature: _______________________________________________________________ Print Name: _______________________________________________________________ Date: _____________________________________ Additional Plan Information *****Please complete upon selecting Empower as your provider***** Legal Name of Plan: Plan Headquartered State: EIN: Plan Year End (MM/DD): Plan Contact for Conversion:First Name: Last Name: Phone Number: Email: Is the Financial Representative properly licensed to sell in Headquartered State?Y N N/A Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers. GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company. Empower Retirement™ refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY; and their subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A. The Great-West Family of Companies refers to products and services offered through The Great-West Life Assurance Company, London Life Insurance Company, The Canada Life Assurance Company, Irish Life Assurance Company, Great-West Life & Annuity Insurance Company, Putnam Investments, LLC, and their affiliates and subsidiary companies. 10/31/2023 8:50:07 AM (409427) (P-F MA-MTR) Then Page 11 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 10/31/2023 Scott Carroll Payment Request Form V03052020 Insurance products offered by Great-West Life & Annuity Insurance Company, Corporate Office: Greenwood Village, CO In New York, by Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY. Plan Information Plan Name ___________________________________________________________________ Plan Number ________________________ Payee Information EIN/Taxpayer ID New Partner/Payee Existing Partner/Payee EIN/Taxpayer field must be completed for every request. IRS Form W-9 must accompany this request. EIN and Payee fields are required. Payee (Must match name on W-9) __________________________________________________________________________________________ You must complete the rest of this section if you are a new partner/payee or if existing partners/payees need to make updates to the information already on file. Address ______________________________________________________ City _____________________ State ________ Zip ____________ Phone # __________________________________ Email Address: ___________________________________________________________ (For reporting purposes, a back office email address is recommended) Investment Advisory Services Firm - Advisor(s) Name Printed: ______________________________________________________________ Third Party Administrator (“TPA”) Trustee Auditor Legal Counsel Other ______________________________ Form of Payment ACH Bank Name _________________________________________________________________________________________________ Account Number ABA or Routing Number _______ NSCC/DTCC Clearing # ______________________________________ Associated Clearing # (if applicable): _____________________ CHECK (Payment will be mailed to above Payee address.) Source, Amount and Frequency of Payment Debit Plan Expense Account (PEA) If the balance in the PEA is insufficient, payment will generate for balance available. If applicable, recurring payment calculation to start as of first day of (month/quarter) __________________ (year) _____________. If left blank, payment calculation begins as of the first of the month in which the form was received. One Time Flat Dollar Amount $ ____________________ Recurring Annual Flat Dollar Amount $ ____________________ prorated and paid Monthly Quarterly One Time Basis Points Payment ____________________ Recurring Annual Basis Points _____________________ prorated and paid Monthly Quarterly Recurring Annual per Participant Charge $ _____________________ prorated and paid Monthly Quarterly Debit Forfeiture Account One Time payment of $ ______________________ prorated across all available money types (including PEA) unless specified below. Only debit the following specific money type(s) _____________________________________________________________ Debit Participant Accounts If applicable, recurring payment calculation to start as of the first day of (month/quarter) ______________________(year)_____________ If left blank, payment calculation begins as of the first of the month in which the form was received. Flat Dollar Amount $ _________________ One Time Payment to recur annually - prorated and paid Monthly Quarterly Debit the dollar amount indicated pro-rata or if selected Per Capita – an identical amount across all accounts. Basis Points __________________ One Time Payment to recur annually - prorated and to be paid Monthly Quarterly Per Participant Charge $ __________________ One Time Payment to recur annually - prorated and paid Monthly Quarterly Individual Participant Only ___________________________________________________ Debit participants on attached spreadsheet (Provide full name, social security # and amount) (Provide full names, social security #’s and amounts) Pay Recurring Invoices Pay this and all future invoices received from the payee listed above when accompanied by a copy of this signed Payment Request Form. To discontinue the payment of invoices for this payee, written notification must be sent to Partner Services at the address listed on page two. Select the source you would like to pay invoices from by indicating a “1”. To offer flexibility, you can select multiple sources so as exhausted, the next source designated with a “2” will be used and then ‘3” if applicable. You do not have to select multiple sources. Plan Expense Account _______ Participant Accounts_______ debited pro-rata or Per Capita (identical amounts) Forfeiture Account _______ all money types or only debit the following specific money type(s) ____________________________________ The forfeiture account will be processed using all money types, including PEA, unless otherwise specified. Costa Mesa Sanitary District 2 0 1 4 0 9 6 1 3 4 Envestnet Retirement Solutions, LLC 1801 California Street, 23rd floor Denver CO 80202 (866) 924-8913 ERS-Billing@envestnet.com 4 Fiduciary Services 4 BMO Harris Bank, N.A. 2465565 071000288 ASAP 2024 5bps 4 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Payment Request Form V03052020 Insurance products offered by Great-West Life & Annuity Insurance Company, Corporate Office: Greenwood Village, CO In New York, by Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY. Reallocate PEA Balance Reallocate the PEA based on participant balances as of (MM/DD/YYYY) ____________ Reallocate $ _____________________. If no amount provided, the PEA balance as of the date of receipt of this request will be used. Allocations are processed pro-rata across all money types based on participant balances on the date listed above unless otherwise requested. Credit participant accounts on a per-capita basis (identical amounts) across all money types as of the date listed. If per capita is selected, please contact your account representative for additional information on the participant list that is required. Plan Representative Authorization By signing below, you (the “Authorized Plan Representative”) on behalf of the Plan and Plan Sponsor acknowledge and agree that: You are authorized to provide the payment instructions reflected on this form on behalf of the Plan and have determined that engaging the services of the Payee for a fee is permissible under applicable law, including U.S. Department of Labor and Internal Revenue Service guidance and the terms of the Plan. You have determined that the payment from the Plan you have described via this form represents eligible Plan expenses that may be paid from Plan assets in the manner in which you have designated herein and that such expenses are necessary and reasonable costs associated with administration of the Plan. You acknowledge and agree that, to the extent applicable, the Plan fiduciaries have satisfied the disclosure requirements under ERISA §404(a)(5). You have previously determined an appropriate investment option for the PEA assets, if applicable. If PEA assets are invested in a variable investment option, the amount of PEA assets available to pay plan expenses is limited to 95% of the PEA balance at the time the payment is processed to account for market fluctuation. In the event that a requested payment from the Plan is to be made to an Investment Advisory Services Firm, you have determined that such direct payment is permissible under applicable law. In the event that a requested payment from the Plan is to be made to the Plan Sponsor, you have determined that the payment does not result in a non-exempt prohibited transaction or other violation of the Code, ERISA or any other applicable law and is otherwise permissible under the terms of the Plan. The Plan acknowledges and agrees that Empower is not a Plan fiduciary and is acting solely at your direction as a remittance or paying agent, and has not performed any due diligence on any Payee, negotiated the terms of the Payee’s compensation, determined the compensation paid by the Plan to the Payee is deemed to be reasonable under applicable law, or advised on the means or manner of remitting the Payee’s compensation. You instruct Empower to reclaim from the Payee any and all funds paid to the Payee over the amount the Payee is entitled to receive per the Plan Sponsor’s payment instructions as reflected on this form. You agree that the payment processing services you have authorized via the instructions reflected on this form will be provided by Empower subject to the terms of the recordkeeping services agreement between the sponsoring Employer and Empower. You may terminate this Authorization at any time by notifying Empower in writing prior to the time that a payment is processed. Any termination of this Payment Authorization will not be effective until written notification is received in good order at the contact information provided below. You acknowledge and agree that Empower is entitled to rely on this Authorization and is released from liability for any payments made pursuant to it. Upon termination of the recordkeeping services agreement with Empower, recurring monthly payments will not be processed for the month of the scheduled liquidation date or any month thereafter. Quarterly payments will not be processed for the quarter of the scheduled liquidation date. Payments will not be processed from any remaining Plan assets subject to a put or any other applicable liquidation restriction following the Plan’s de-conversion. In the case of a plan termination, recurring flat dollar payments paid monthly will not be paid in the month the termination is effective or any month thereafter. Quarterly payments will not be processed for the quarter in which the termination is effective or any month thereafter. Recurring payments from basis points and per participant charges will continue for any full month or quarter until the plan assets are fully liquidated. __________________________________________________ _____________________________________ Authorized Plan Representative Signature Date ____________________________________________________ Print Name Empower Retirement Partner Services Contact Information: E-mail: PartnerServices@empower-retirement.com Fax: (303) 737-1499 Mail: Empower Retirement ATTN: Partner Services 8525 East Orchard Road 9T3 Greenwood Village, CO 80111 DocuSign Envelope ID: 0FA201EF-C559-4A47-8233-4E1095D9D2E8 Scott Carroll 10/31/2023 Certificate Of Completion Envelope Id: 0FA201EFC5594A4782334E1095D9D2E8 Status: Completed Subject: Complete with DocuSign: Empower's Proposal for Costa Mesa Sanitary District - 10.31.2023.pdf, P... Plan Number: Category: Client Service Representative Email: Client Service Representative Name: Social Security Number: Source Envelope: Document Pages: 13 Signatures: 2 Envelope Originator: Certificate Pages: 8 Initials: 0 Kenji Goldman AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-08:00) Pacific Time (US & Canada) PO Box 1700 Denver, CO 80201 kenji.goldman@empower.com IP Address: 143.199.125.10 Record Tracking Status: Original 10/31/2023 9:06:43 AM Holder: Kenji Goldman kenji.goldman@empower.com Location: DocuSign Signer Events Signature Timestamp Scott Carroll scarroll@cmsdca.gov Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 76.79.206.98 Sent: 10/31/2023 9:11:47 AM Viewed: 10/31/2023 9:12:37 AM Signed: 10/31/2023 9:14:18 AM Electronic Record and Signature Disclosure: Accepted: 10/31/2023 9:12:37 AM ID: 036fdfa6-7257-4664-8614-94821fd3afba Company Name: Empower In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Kenji Goldman kenji.goldman@empower.com Security Level: Email, Account Authentication (None) Sent: 10/31/2023 9:11:47 AM Resent: 10/31/2023 9:14:20 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 10/31/2023 9:11:47 AM Certified Delivered Security Checked 10/31/2023 9:12:37 AM Signing Complete Security Checked 10/31/2023 9:14:18 AM Completed Security Checked 10/31/2023 9:14:18 AM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE CONSENT AGREEMENT The purpose of this Electronic Record and Signature Consent Agreement (“Agreement”) is to formally agree to receive electronically and use an electronic signature on one or more of the document(s) included in the electronic envelope on the Docusign system (“Document Package”). By accepting this Agreement, you are agreeing that electronic signatures and electronic delivery (i.e., email or posting to a website) are the legal equivalent of an actual physical signature and actual physical delivery, respectively, for purposes of the Document Package. This Agreement is voluntary. This Agreement is only required if you want to electronically sign and receive the Document Package. If you do not want to electronically sign and receive the Document Package, do not check the ‘I agree to use electronic records and signatures’ box. If you do not want to electronically sign the Document Package, contact Empower for a standard PDF file that you can print and execute with wet signatures and return via regular mail. If you have any problems accessing PDF documents, contact Empower to discuss alternative arrangements. Note that even if you agree to electronically sign the Document Package, in the future after receiving an electronic document package, you will be able to choose whether or not to electronically sign that document or ask for another version to sign. Please confirm your acceptance by checking the ‘I agree to use electronic records and signatures’ box. By checking this box, you acknowledge that you have carefully and thoroughly read the information below, you can access this information electronically to your satisfaction, and you agree to these terms and conditions: 1. Definitions: The words “you” and “your” mean the account owner of the account. Electronic Record and Signature Disclosure created on: 1/20/2023 1:17:48 PM Parties agreed to: Scott Carroll “Empower” and the words “we,” “our,” and “us” mean Empower Annuity Insurance Company of America and its affiliates, successors, and assigns, including but not limited to Empower Life & Annuity Insurance Company of New York, Empower Funds, Inc., Empower Trust Company, LLC, Empower Capital Management, LLC, Empower Advisory Group, LLC, and Empower Financial Services, Inc. as applicable. 2. Scope of this Agreement: This Agreement only applies to the electronic signatures and electronic delivery of the Document Package. This Agreement does not apply to any situation by law or otherwise that requires you to provide written notice or document to us, which must be done on paper unless we provide instruction to you how to deliver the item to us electronically. We may, in our sole discretion, choose to provide you with any document on paper, even if you have authorized electronic delivery. 3. Electronic Signatures: By accepting this Agreement, you consent to use electronic signatures for the Document Package, and you agree that electronic signatures shall be deemed to be legally equivalent to actual physical signatures. The electronic signature process will be facilitated through DocuSign, Inc., which is separate company retained by us to facilitate this service, but has no other affiliation with Empower. One or more electronic documents will be included in an electronic envelope on the Docusign system and a link to the envelope will be e-mailed to you. These electronic documents may include but are not limited to service and account agreements between you and us, along with transaction forms and other documents related to your account with us. 4. Authentication and Qualified Security Procedures: The electronic signature process through DocuSign provides authentication through the use of a digital audit trail. Generally, “authentication” refers to the act of attributing an electronic signature to the individual that signed the document, and determining that the document has not been changed since its execution. In order to electronically sign the Document Package, you will need to access a unique link sent to your email address that you provided to us. After signing the Document Package, we will receive a court-admissible “Certificate of Completion.” This “Certificate of Completion” contains a digital audit trail of the transaction, including the signer names, authentication history, digital signatures, email addresses, signer IP addresses, chain of custody (i.e., sent, viewed, signed, etc.), trusted timestamps, geolocation capture of the signer (if provided), and completion status. By accepting this Agreement, you agree that these authentication and qualified security procedures are commercially reasonable. 5. Electronic Delivery: By accepting this Agreement, you agree the electronic delivery of the Document Package emailed to you, is the legal equivalent of actual physical delivery, such as delivery by the United States Postal Service or hand-delivery, whether or not you actually see or view the Document Package. For purposes of this agreement, unless we receive actual notice of a delivery failure, we shall be deemed to have conclusively delivered the Document Package to you when we attach and send the document(s) to the email address that you provided to us. 6. Updating Your Email Address and Other Contact Information: It is your responsibility to provide us with accurate and complete e-mail address and other contact information. You agree to maintain and promptly update any changes in this information. 7. Withdrawing Your Consent: We will ask for your consent each time we present an envelope of electronic documents to you. Once you give your consent for that envelope, you cannot withdraw it for that envelope but you can still choose not to sign any or all electronic documents included in that envelope. In addition, before you execute an electronic signature in DocuSign, the DocuSign system allows you to exit the electronic signing process. You should inform us that you no longer want to electronically sign and then receive the document(s) in another manner by emailing Empower directly with your request. 8. Requesting Paper Copies: At any time, you may request from us a paper copy of any record that we provided or made available electronically to you. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after the signing session. If you elect to create a DocuSign signer account, you may access them for a limited period of time, typically 30 days after such documents are first sent to you. Additionally, subject to our document retention procedures, you may contact us and request another electronic or paper copy of the Document Package. If you wish for us to send you paper copies of any such documents, you will be charged a $0.00 per-page fee. You may request a paper copy of the Document Package by contacting Empower directly with your request. 9. Required Hardware and Software: Operating Systems: Windows XP, Windows Vista®, Windows® 7, Windows® 8 or higher; Mac OS® X or higher Browsers: Final release versions of Internet Explorer® 9.0 or above (Windows only); Mozilla Firefox 35 or above (Windows and Mac); Safari™ 7.0 or above (Mac only), Chrome 40 or above PDF Reader: Acrobat® or similar software may be required to view and print PDF files Screen Resolution: 1024 x 768 minimum Enabled Security Settings: Allow per session cookies; Users accessing the Internet behind a Proxy Server must enable HTTP 1.1 settings via proxy connection These minimum requirements are subject to change. If these requirements change before the Document Package is fully executed, you will be asked to re-accept this Agreement. Pre-release (e.g. beta) versions of operating systems and browsers are not supported. 10. Docusign We have entered into an agreement with DocuSign, Inc. (“DocuSign”) to make their electronic system available to facilitate your receipt and electronic signature of the Document Package. Your use of the DocuSign system is subject to the terms and conditions of DocuSign’s system. We are not responsible for the DocuSign system and we disclaim any representations and all warranties regarding the DocuSign system. 11. Acknowledgement and Consent: To confirm to us that you can access this information electronically, please verify that you were able to read this Agreement and that you also were able to: print on paper or electronically save for your future reference and access, or that you were able to e- mail to an address where you will be able to print on paper or save it for your future reference and access. By checking the ‘I agree to use electronic records and signatures’ box, I confirm that: o I meet the required hardware and software requirements listed above; o I can access and read this Agreement; o I can print on paper the Document Package or save or send the Document Package to a place where I can print it for future reference and access; o I have read this Agreement and agree to be bound by its terms and conditions. 12. Contacting Empower Please contact us to let us know of changes as to how we may contact you electronically, to request paper copies of certain information to us, and to withdraw your consent to receive the Document Package: To contact us by e-mail: retirementsolutionsservice@empower.com To contact us by phone: 866-317-6586 “EMPOWER” and all associated logos and product names are trademarks of Empower Annuity Insurance Company of America. ©2022 Empower Annuity Insurance Company of America. All rights reserved. www.empower.com