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RESOLUTION
RE: APPROVAL OF 401K PLAN AGREEMENTS AND AUTHORIZATION FOR THE
CHAIRMAN TO SIGN SAME.
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, pursuant to Colorado statute and the Weld County Home
Rule Charter, is vested with the authority of administering the
affairs of Weld County, Colorado, and
WHEREAS, on the 26th day of September, 1983 , the Board of
County Commissioners established a Deferred Compensation Plan
for its employees and selected Shirazi and Associates' proposal
of National Plan Coordinators as the plan administrator, and
WHEREAS, the Board of County Commissioners have appointed a
Deferred Compensation Board to oversee the Deferred Compensation
program, and
WHEREAS, the Deferred Compensation Board has recommended
offering a 401K, as well as the 457 plan to County employees,
and
WHEREAS, on October 2 , 1984 , the Deferred Compensation
Board reviewed 401K programs submitted by National Plan
Coordinators, Safeco, Hartford Insurance, General American and
Bankers Life, and
WHEREAS, the Deferred Compensation Board has recommended
that the 401K plan offered by Bankers Life be approved by the
Board of County Commissioners for Weld County employees, and
WHEREAS, the Board has been presented agreements between
Weld County and Bankers Life, copies of said agreements being
attached hereto and incorporated herein by reference, and
WHEREAS, after study, the Board deems it advisable to
approve said agreements and authorize the Chairman to sign same.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County, Colorado, that the aforementioned
agreements be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board of County Commissioners
that the Chairman be, and hereby is, authorized to sign same.
841279
f fl
The above and foregoing Resolution was, on motion duly made
and seconded, adopted by the following vote on the 29th day of
October, A.D. , 1984 .
BOARD OF COUNTY COMMISSIONERS
ATTEST: Q, .+y, ,, ELD COUNTY, COLORADO
Weld County Clerk and Recorder
and Clerk to the Board Norman Carlson, Chairman(2B Orw ricc.c. r ) Jai •wine Jo n n, Pro-Tem
De uty County Clerkit 0-4g44.7tr•
APPROVED AS TO FORM: ene Brantner
y�
Ci��^�i EXCUSED
Chuck Carlson
County Attorn -.0
n Martin
Y fl T l
I#k401 I SERVICE AGREEMENT
In this agreement. . .you and your means employer.
We, us, or our means Bankers Life Company of Des Moines, Iowa.
REGULAR SERVICES
THE REGULAR SERVICES PROVIDED BY THE GENERAL ADMINISTRATION AND RECORDKEEPING EXPENSE
CHARGES INCLUDE THE FOLLOWING:
1. Representatives to help explain and discuss the plan with employees.
2. Preparation of the contract and help in drafting sample plan documents.
3. Annual summary of the amounts held in all Members' accounts (both General Investment Accounts and Separate
Investment Accounts) showing earnings credited, deposits and withdrawals.
4. Periodic determination of each Member's account values on assets held by us. Reports of these values are fumished
annually.
5. Annual benefit report for distribution to each Member.
6. Help in preparing forms you (or your counsel) will need to submit to the IRS requesting approval as a qualified plan.
7. Help with your annual reporting requirements under ERISA.
8. Administration manual and forms needed to assure simplified handling of your plan.
9. Continuing help as changes in legislation occur which may affect your plan.
10. Allocation of your contribution to each individual Member. NOTE:This allocation will be final and conclusive, unless the
Contractholder, within 30 days following receipt of the allocation report, gives us written notice that the report is not
acceptable.
11. Record of Member beneficiary designations and certificates for all Members.
12. Calculation of benefits at retirement, termination, death or disability.
OPTIONAL SERVICES
401(k) - THE DEFERRAL PERCENTAGE TEST UNDER SECTION 401(k)(3) OF THE INTERNAL REVENUE CODE
The test for discrimination will be performed as frequently as you request based on the information you provide.
Upon completion, we will send you a summary of the results of each test. This summary will show whether the test was
passed or failed and the deferral percentages by individual. If requested, the salary and contribution amounts used for the
test will be listed.
BOOKLETS (Summary Plan Description)
The Contractholder may request that we draft and/or print booklets.The services of drafting and/or printing the booklets are
provided at no extra charge if(1)we receive 100%of plan deposits,and(2)the booklet is of a standard design[i.e. up to 40
pages in length, up to 3 black cuts (logo on cover and/or letterhead and signature cut for letter) and one of 24 standard
covers]. If a nonstandard design is requested or the plan is split-funded,we will determine the cost and charge it to you.We
will tell you of the cost before the service is performed.
GP 23165
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SCHEDULE OF OUR CHARGES FOR SERVICES UNDER FIA/401(k) CONTRACTS
GENERAL ADMINISTRATION EXPENSE CHARGE
If the Average Balances is
OVER BUT NOT OVER AMOUNT OF ANNUAL CHARGE
$ 0 $ 100,000 .840% of the balance **
$ 100,000 $ 300,000 .420% of the balance + $ 420
$ 300,000 $ 1,000,000 .251% of the balance + $ 927
$ 1,000,000 $ 3,000,000 .167% of the balance + $ 1,767
$ 3,000,000 $10,000,000 .123% of the balance + $ 3,087
$10,000,000 '$30,000,000 .081% of the balance + $ 7,287
$30,000,000 and over .059% of the balance + $13,887
EXAMPLE: Assume a $2,000,000 average balance; charge is $2,000,000 times .00167 = $3,340 + $1,767 = $5,107.
•Average balance means the total of all Members' General Investment Accounts and Separate Investment Accounts and Holding
Accounts under the contract at the beginning of each Deposit Year adjusted by time weighted additions to and withdrawals from the
accounts during the year.
"Minimum annual charge $725.
STANDARD RECORDKEEPING EXPENSE CHARGE
Number of Accounts* for Non-Retired Members
OVER BUT NOT OVER ANNUAL CHARGE
0 10 $14.65 per account minimum annual
10 30 $ 9.05 per account + $ 56.00 charge is$300**
30 100 $ 6.79 per account + $ 123.80
100 300 $ 4.99 per account + $ 303.80
300 1,000 $ 3.41 per account + $ 777.80
1,000 and over $ 1.55 per account + $2,637.80
EXAMPLE: Assume 1,000 accounts; charge is 1,000 times $3.41 = $3,410.00 + $777.80 = $4,187.80. This would be
$4.19 per account, per year.
*Depending on plan design a Member may have more than one account.(Any account in which the Member participated during the year
is taken into consideration in determining this charge.)
"If this contract is combined with one or more contracts for determining the General Administration Expense Charge, the minimum
annual $300 charge will be reduced to $240 for each combined contract, but there will be no other combination for the Standard
Recordkeeping Expense Charge.
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401(k) - THE DEFERRAL PERCENTAGE EXPENSE CHARGE
You will be charged for each test performed. Such charges are payable within 31 days from the date of the statement.The
charge for each test is:
The sum of (1) $25.00, plus
(2) $ 0.25, for each Member* included in the test.
*Members who make no deferral must be included in calculating the average.
COMPENSATION TO AGENT, BROKER, OR CONSULTANT ("Agent")
Compensation paid by us will be paid according to the compensation agreement between us and the Agent, based on the
deposits made to the contract, and according to the following scale or portion thereof. The Compensation includes an
amount for initial and continuing help for enrolling Members into your 401(k) plan.
On that Part of the Net Deposits for a Given Deposit Year (excludes any expense money paid separately):
Deposits Over But Not Over Compensation to Agent
$ 0 $ 50,000 3.00% of the deposit
$ 50,000 $100,000 2.00% of the deposit + $ 500
$100,000 $500,000 1.00% of the deposit + $1,500
$500,000 and over .50% of the deposit + $4,000
EXAMPLE: Assume a $55,000 Net Deposit; Compensation is $55,000 x .02 = $1,100 + $500 = $1,600.
On Account Values Converted to Immediate Annuity Income:
Account Values Over But Not Over Compensation to Agent
$ 0 $ 50,000 3.00%of the Account Values
$ 50,000 $100,000 2.00%of the Account Values + $ 500
$100,000 $500,000 1.00%of the Account Values + $1,500
$500,000 and over .50%of the Account Values + $4,000
EXAMPLE: Assume $75,000 of Account Values; Compensation is $75,000 x .02 = $1,500 + $500 = $2,000.
GP 23185
fl CONTRACT NO.
Ir SERVICE AGREEMENT FOR FIA/401 k CONTRACTS In Ms agreement...you and your means employer.
We, us, or our means Bankers LOU Company of Des Moores, Iowa.
The General Administration Expense Charge: 401(k) Deferral Percentage Test:
1. 6 Will be paid by you to us as billed. 1.'® Is to be performed by us.
2. 0 Is to be deducted from the Member's accounts and 2. r&Is not to be performed by us.
from the Holding Accounts and apportioned
among these accounts based on their value. Summary of Test:
The Standard Recordkeeping Expense Charge: 1. ® Show deferral percentage, salary used, and
contribution amounts, per Member.
1. ® Will be paid by you to us as billed.
2. 0 Show only deferral percentage per Member.
2. 0 Is to be deducted from Member accounts based on
the total charge divided by the number of You will be charged for each test completed.Such charges
accounts used to determine the charge. can not be deducted from Member Accounts.
NOTE: Standard recordkeeping provides a report to you
(Display of Accounts) and reports tor the Members Compensation to Agent, Broker, or Consultant ("Agent")
(Benefit Plan Reports and Benefit Illustrations). These and Compensation Arrangement:
reports are provided after the Deposit Year and again The Contractholder names Maanttrl Shiraz{
after your annual deposit is made and alloca- (Agw)
ted to Members' Accounts. More frequent reports Compensation is to be paid:
are available for an extra charge. If you want more 1. 0 Directly by you to the Agent.
frequent reports check the appropriate box be- 2. ® To the Agent by us. You will reimburse us as billed.
low:
Reports and Charges based on Deposit Year In addition, under 2 above, Compensation will be paid on
Member account values converted to immediate annuity
1. 0 Semi-annually (1% increase in annual rec- income under this contract. Provision for this compen-
ordkeeping charge) sation will be included in the annuity purchase rates.
2. ® Quarterly (3% increase in annual recordkeeping
charge) The start-up expense charge of $250, which
3. ❑ Monthly (11% increase in annual recordkeeping must accompany the application for the contract, is
charge) NONREFUNDABLE and
Member reports as often as yours 1. fi Is a business expense separate from plan deposits.
❑ Yes ['} No 2. ❑ Is to be deducted from plan deposits.
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If No checked Member reports will be made
annually.
Services not included in this agreement may be provided upon mutual agreement between us and the Contractholder.The
services provided above and the charges associated with them,except Agent Compensation,can be modified or withdrawn
upon 60 days written notice from us to the Contractholder.
This agreement will be:
1. ® Effective as of 1 l i 85 and upon receipt in our Home Office,unless we notify you within 60 days after
receipt that ft is not acceptable.
2. 0 Reyised and effective as of�J—!—�and upon receipt in our Home Office,and replaces all such prior
i `' A ` agreements, unless'we notify you within 60 days after receipt that it is not acceptable. `
NOTE: T h.Is‘greement fs tenninand on tfre'etrair of:(1)the date on which a ie' ed egreerneneis accepted by us at our Home Office,or •
(ii) the date on which there are no accounts under the contract.
BANKERS LIFE COMPANY n,
44,
By: v�9 MUMMY Title: President
CONTRACTHOLDER EMPLOYER (If different from Contractholder)
Exact name: weld r''ottn*y Exact name:
By: X By:
Title: — Title:
Date signed:)( / —a 9— Date signed:
GP 23165 A
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TH E BAN KERS LI FE NOWLEDGEMENT OFCOMMISSION AND
BANKERS LIFE COMPANY DES MOINES,IOWA 50307 CONTRACT INFORMATION
SCA/401(k)
Masoud Shirazi
Name of Soliciting Agent
Shirazi & Associates
Agent's Firm Name, it any
P.O. Box 2455, Greeley, CO 80632
Address
Type of Bankers Life Company Annuity contracts) The soliciting agent is affiliated with Bankers Life
under consideration: Company as:
I Broker
Full-time agent of Bankers Life Company
Employee (i.e., agency manager or supervisor of
Flexible Investment Annuity/401(k) Bankers Life Company)
NOTE: Always check the box for"Broker" unless the soliciting
agent is a full-time agent of Bankers Life Company or an
employee of Bankers Life Company.
The soliciting agent isn't limited by any agreement with Bankers Life Company in the contracts he or she can recommend for
purchase.Exception:full-time agents and employees of Bankers Life Company must,on individual policies of life insurance,give
Bankers Life Company first opportunity to offer a policy.
The amount of commissions to be paid the soliciting agent by Bankers Life Company as a percentage of contributions(excluding
expense money paid separately) to the contract(s) under consideration:
Contributions For Each Year
The first $ 50,000 3.00%
The next 50,000 2.00
The next 400,000 1.00
The next 2,500,000 0.50
Excess over 3,000,000 0.25
Any portion of contributions that represents transfer assets will be considered by Bankers Life Company for payment of •
commissions, if any, as part of the scale above.
In future years,if plan eligibility or benefits are increased by amendment, under some circumstances separate commissions for
one year might be paid on the increase. If so, the rates will be the same as those above.
When Member Account Values are converted to immediate annuity income, additional commissions may be paid. if
commissions are payable, they will be paid according to the following schedule:
Immediate Annuity Premium For Each Year
The first $ 50,000 3.00%
The next 50,000 2.00
The next 400,000 1.00
The next 2,500,000 0.50
Excess over 3,000,000 0.25
I acknowledge receipt of this informational sheet given me by the soliciting agent-I have received it before making (or before
others under my direction make)application for the Bankers Life Company contract(s)under consideration.I understand that
f application for the Contract(s)Is my approval that the soliciting agent arrange the purchase of the contract(s)from Bankers Life K 14:
and receive these commissions.I am not receiving for my personal account any compensation of other '
- din or indirectly' — fromplan anyone dealing with the in connection with this purchase of Contract(s)
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I also acknowledge that I have been given the written Description of the Bankers Life Company Group Annuity Contract
ma V above.
Signature r
(of person signing 64 /al-SOW
the Employee Plan) x Date Signedd r
X �0 2 n A 4/ d4 /2 L SON X ,4,,,,,,4,,,`
Typed or Printed Name of Person Signing Title
Weld County
Name of Employee Benefit Plan (need not be formal name — just so identifies plan) •
Distribution of copies: Original for Bankers Life Company; first carbon for agent; second carbon for person signing for plan.
Flexible Investment Annuity/401(k)
ox 54
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( APPLICATION FOR
GROUP ANNUITY CONTRACT
Application is made to
BANKERS LIFE COMPANY
711 High Street
Des Moines, Iowa 50307
Weld County
(Exact name of Applicant;e.g.,"XVZ Co..Inc.'or if Trusteed;e.g.. 'Trustee of ABC Co.,Inc.Retirement Plan")
Greeley, Colorado
(Applicant's CM&State)
The Applicant applies for the following group annuity contract:
❑ Deposit Administration (DA)
❑ Fixed Interest Funds (FIF)
[Xj Flexible Investment Annuity (FIA)
❑ Flexible Investment Annuity - 1 (FIA)
❑ Group Accumulation Annuity (GM)
❑ Immediate Participation Guarantee (IPG)
❑ Investment Value Account (IVA)
❑ Investment Value Fund (IVF)
❑ Investment Value Plus (IVP)
❑ Retirement Investment Annuity (RIA)
❑ Single Premium (SP) •
O
State of delivery of this contract shall be Colorado
Advance payment of$ 250.00 is submitted with this application to be applied under the contract.
The effective date of the contract shall be 1/1/85
It is agreed that acceptance of any contract issued shall constitute approval by the applicant of the provisions in
such contract as being in accord with this application.
A determination letter stating that the applicant's plan(including any pending changes)qualifies under Section
401(a)of the Internal Revenue Code
►i has been or will be requested, O has been received. ❑ is not intended to be requested.
Signed at Greeley, Colorado this X -19 day of x tiDc.'r , 19 84
(City) (State)
licit' gent Person signing for Applicant
Title(Trustee,it applicable)
GP 19170-1 THE BANKERS LIFE 00
BANKERS LIFE COMPANY DES MOINES, IOWA
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