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MissionSquare Retirement Health Savings Program Return Book <br />XIII. Employer Acknowledgements <br />A. The Employer hereby acknowledges it understands that failure to properly fill out this <br />MissionSquare Retirement Health Savings Adoption Agreement may result in the loss of tax <br />exemption of the Trust and/or loss of tax -deferred status for Employer contributions. <br />B. 34 Check this box if you ar `E)uding supporting documents that include plan provisions. <br />Employer Sig <br />By: 6 <br />Title: <br />Attest: <br />Title: Ei <br />Date: 1 2-1iv iZ Z <br />Date: 12110 JZ5' <br />14 <br />