ASEA/AFSCME LOCAL 52 HEALTH BENEFITS TRUST
ACCEPTANCE OF ELECTION AS TRUSTEE
The undersigned, having been duly designated as a Trustee of the ASEA/AFSCME Local 52 Health Benefits Trust, does hereby accept the Trust created and established by the ASEA/AFSCME Local 52 Health Benefits Trust - Trust Agreement as Amended and Restated effective September 28, 2005 (hereafter the Agreement and Declaration of Trust) and agrees to act as a Trustee and to administer the Trust Fund in accordance with all the terms and conditions set forth in the Agreement and Declaration of Trust. Further the undersigned agrees that he/she has fully read, understands and agrees to the provisions outlined in the "Requirements for Electing Board of Trustee Members for the ASEA/AFSCME Local 52 Health Benefits Trust" and the "ASEA/AFSCME Local 52 Health Benefits Trust Board of Trustees Qualifications and Requirements List" documents.
Additionally, the undersigned certifies he/she understands that section 411(a) of the Employee Retirement Income Security Act of 1974 (ERISA) provides that no person who has been convicted of or has been imprisoned as a result of a conviction of robbery, bribery, extortion, embezzlement, fraud, grand larceny, burglary, arson, a felony violation of Federal or State law involving substances defined in section 102(6) of the Comprehensive Drug Abuse Prevention and Control Act of 1970, murder, rape, kidnapping, perjury, assault with intent to kill, any crime described in 9(a)(1) of the Investment Company Act of 1940, a violation of any provision of ERISA or section 302 of the Labor Management Relations Act of 1947, a violation of section 63 of Title 18, United States Code, a violation of sections 874, 1027, 1503, 1505, 1506, 1510, 1951, and 1954 of Title 18, United States Code, a violation of the Labor-Management Reporting and Disclosure act of 1959, any felony involving abuse or misuse of a position or employment in a labor organization or an employee benefit plan to seek or obtain an illegal gain at the expense of the members of the labor organization or the beneficiaries of the employee benefits plan, or a conspiracy to commit or attempt to commit any such crimes, or a crime in which any of the foregoing crimes is an element, shall be permitted to serve as an administrator, fiduciary, officer, trustee, custodian, counsel, agent, employee, representative, advisor or consultant to any employee benefits plan or in any capacity involving decision making authority or custody or control of the assets of any employee benefits plan during or for 13 years after such conviction or after the end of such imprisonment, whichever is later, unless the sentencing court on motion of the person convicted sets a lesser period of at least three years after the end of such conviction or imprisonment, whichever is later, or unless prior to the end of the period, citizenship rights revoked as a result of such conviction have been fully restored or if the United States District Court for the district in which the offense was committed, approves of service in one of the aforementioned capacities with respect to the Plan.
Further, the undersigned certifies that he/she has not been convicted or imprisoned on account of the aforementioned offenses and that his/her acceptance herein is not contrary to the provisions of section 411(a) of the Employee Retirement Income Security Act of 1974, which has been adopted as a guideline for the fiduciary standards applicable to the ASEA/AFSCME Local 52 Health Benefits Trust.
Finally, the undersigned agrees to follow all administrative policies and procedures approved and set forth by the Board of Trustees.
Dated this ________ day of ________________, 2007
