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2017 ACA Order Form for Citv of South Bead <br />This order forth, effective July 3, 2017 constitutes a Services Agreement between AccordWare LLC and City of South Bend, <br />hereafter referred to as Company and Client respectively, for ACA Reporting Services. By executing this order form, Client <br />accepts the following: <br />Purpose <br />Client wishes to engage Company to assist with fulfillment of its reporting obligations pursuant to the Patient Protection and <br />Affordable Care Act, more specifically, populating and communicating the necessary information to satisfy Section 6055 and <br />6056 (Forms 1094-C & 1095-C) reporting requirements with regard to the Internal Revenue Service. <br />Obligations & License <br />Client will furnish and manage the necessary data for Company to meet this obligation. Client will respond promptly to <br />questions and issues raised by Company in the course of fulfilling their reporting obligations and execute any documentation <br />necessary in this regard. <br />Client will retain ownership and control of said data, and Company shall use same only as necessary to meet Client's reporting <br />obligations. Company shall retain ownership of their methods, software, processes, and any other intellectual property or <br />proprietary items, which shall be licensed to the Client as needed to fitlfill the purposes of this Addendum, only. <br />Client acknowledges that entering into a reporting arrangement does not transfer the potential liability of the provider for failure <br />to report information and furnish statements under section 6055. <br />2017 REPORTING SERVICE FEES <br />Client Service &/or <br />Application Software <br />Title <br />Reporting Service Fees <br />Postage* <br />Annual Base Fee <br />ACA Reporting IRS <br />$1.00 Per Employee Analyzed <br />Forms 1094-C <br />$1 25 <br />TBD <br />$750.00 <br />& 1095-C <br />Per1095-C Form <br />* Postage is billed as an at cost pass through cost to employer <br />ADDITIONAL TERMS <br />Product Availability. As provided in Exhibit B below, Client acknowledges that several steps must occur <br />following the execution of this order form to prepare the application software for Client's use. The parties <br />estimate that these steps will be completed, and that the application software will be available for use by Client <br />on or about December 1, 2017 (the "Product Launch Date"); however, the ability to meet this Product Launch <br />Date depends upon the timely actions of the Client, Company and external parties (i.e. the US Internal Revenue <br />Service, etc.). Both parties agree to use their best efforts to achieve this Product Launch Date, or if they are <br />unable to do so, to modify this order form to reflect a new launch date as close in time as possible to the Product <br />Launch Date. Any change to this Product Launch Date must be agreed to by both Client and Company in <br />writing. <br />Billing, Billing of the Implementation or Annual Base fee will occur on or about December 1, 2017. Total <br />Reporting Service and Postage Fees under this order form will be billed on or about February I, 2018, <br />Term. This order form covers the reporting period for the 2017 calendar year. ("Full Agreement Term"). <br />COSB Order Form 3 Confidential Page I of 4 <br />