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<br />VantageCare Retirement Health Savings Plan <br />Implementation Data Form - Page 2 <br /> <br />Plan Contacts <br />(If any item #16-21 is left blank, the Primary Contact in #5 will receive mailings <br /> <br />Payroll Contact Contact Signature: <br />Information 16. PT01 <br /> (200) Contact Name: L,,^-A 1,' ~ c. ~ t\. \ <br />Please indicate (200) Contact Title: i\50~ . Fll.U."'~""'-'L b;~ <br />alternate (420) Telephone: (1Q5J '1~ 2. - \ 510 S- Fax: <br />addresses in <br />Coments Section 17. PT08 Contact Signature: <br /> (200) Contact Name: <br /> (200) Contact Title: <br /> (420) Telephone: (---.J Fax: <br /> 18. PT09 Contact Signature: <br /> (200) Contact Name: <br /> (200) Contact Title: <br /> (420) Telephone: (---.J Fax: <br />Contribution 19. PT02 (200) Contact Name: ~,,-ck.. 1) ~ 5.c- \ <br />Contact (200) Contact Title: Ac;~ -- 1) <br /> t-~<.. <br />Information (420) Telephone: ~ '792' l.ftD:; <br />Trustee Contact 20. PT10 (200) Trustee Name: <br />Information (200) Trustee Title: <br /> (200) Trustee Address: <br /> Street <br /> City State <br /> (420) Telephone: l-J <br />Billing (Fees) 21. PT06 (200) Contact Name: L\~ ....Jr. ~ll c..o.-\ <br />Contact (200) Contact Title: M-.f'~(.~ "1; <br />Information (421) Telephone: (SbC;) ,qz. - tl?c>"", <br />Comments: <br />(Alternate <br />Addresses for <br />#16-21) <br />Internal Use <br />Only 641 912 608 <br /> - - - <br /> <br />- ...& . <br />-~. <br /> <br />r<;/WIJI /rt.TIAliMr.rn C;O"POR/.TION <br /> <br />:-Dr <br /> <br />~ 7~'2 - (S'''"S <br /> <br />L-) <br /> <br />(---.J <br /> <br />ti:e....:-k,r <br />Fax: ~ '7t(2.-{76~ <br /> <br />Zip <br />Fax: L-l <br /> <br />~, <br />Fax: ~ iqL- \5lS <br /> <br />ICMA Retirement Corporation' Attn: Records Management Unit. P.O. Box 96220 . Washington, DC 20090-6220 . Toll Free '-800669.7400 <br /> <br />21 <br />