__________
FORMAL RECORD OF ACTION

	The following is a formal record of action taken by the governing body of __________ (the "Company").

	With respect to the termination of the __________ (the "Plan"), the following resolutions are hereby adopted:

RESOLVED:  That the Plan be terminated effective ________, with no further contributions to be made under the Plan;

RESOLVED FURTHER:  That the accounts of the participants in the Plan shall be forfeited as of the date of the plan termination;

RESOLVED FURTHER:  That this Plan is a Health Reimbursement Arrangement with unused amounts credited before January 1, 2014, consisting of 1) amounts credited before January 1, 2013 and 2) amounts that were credited in 2013 under the terms of the Plan as in effect on January 1, 2013; 

RESOLVED FURTHER:  That the officers of the Company be, and they hereby are, authorized and directed to take any and all actions and execute and deliver such documents as they may deem necessary, appropriate or convenient to effect the foregoing resolutions including, without limitation, causing to be prepared and filed such reports documents or other information as may be required under applicable law.

Dated this _______ day of _______________, 2013.

						_________________________________

						_________________________________

						_________________________________

NOTICE TO ALL PARTICIPANTS IN THE
__________

[date]

Effective ____________, the __________ (the "Plan") is terminated.  Your account balance will be forfeited in the Plan effective as of the termination.

[OPTIONAL (if elected in D.1 of the plan): you have __________ to submit claims incurred up to the date of termination.]