PSA - ACA Reporting for IRS Forms - AccordWare LLC.

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2019 ACA Order Form for City of South Bend This order form, effective October 21, 2019 constitutes a Services Agreement between AccordWare LLC and City of South Bend hereafter referred to as Service Company and Client respectively, for ACA Reporting Services. By executing this order form, Client and Service Company accepts the following: Purpose Client wishes to engage Service Company to assist with fulfillment of its reporting obligations pursuant to the Patient Protection and Affordable Care Act, more specifically, populating and communicating the necessary information to satisfy Section 6055 and 6056 (Forms 1094-C & 1095-C) reporting requirements with regard to the Internal Revenue Service. Obligations & License Client will furnish and manage the necessary data for Service Company to meet this obligation. Client will respond promptly to questions and issues raised by Service Company in the course of fulfilling their reporting obligations and execute any documentation necessary in this regard. Client will retain ownership and control of said data, and Service Company shall use same only as necessary to meet Client's reporting obligations. Service Company shall retain ownership of their methods, software, processes, and any other intellectual property or proprietary items, which shall be licensed to the Client as needed to fulfill the purposes of this Addendum, only. Client acknowledges that entering into a reporting arrangement does not transfer the potential liability of the provider for failure to report information and furnish statements under section 6055. 2019 REPORTING SERVICE FEES Client Service &/or Application Software Title Reporting Service Fees Postage* Annual Base Fee ACA Reporting IRS $1.00 Per Employee Analyzed Forms 1094-C $1.40 TBD $1,000.00 & 1095-C Per 1095-C Form * Postage is billed as an at cost pass through cost to City of South Bend. ADDITIONAL TERMS Ptcadctt AwaiBalility. As provided in Exhibit B below, Client acknowledges that several steps must occur following the execution of this order form to prepare the application software for Client's use. The parties estimate that these steps will be completed, and that the application software will be available for use by Client on or about December 1, 2019 (the "Product Launch Date"); however, the ability to meet this Product Launch Date depends upon the timely actions of the Client, Service Company and external parties (i.e. the US Internal Revenue Service, etc.). Both parties agree to use their best efforts to achieve this Product Launch Date, or if they are unable to do so, to modify this order form to reflect a new launch date as close in time as possible to the Product Launch Date. Any change to this Product Launch Date must be agreed to by both Client and Service Company in writing. l ill ,n =. Billing of the Implementation or Annual Base fee will occur on or about December 1, 2019. Total Reporting Service and Postage Fees under this order form will be billed on or about February 1, 2020. Term. This order form covers the reporting period for the 2019 calendar year. ("Full Agreement Term"). COSB Order Form 5 Confidential Page 1 of 4