HomeMy WebLinkAboutPSA - AccordWare LLC - Affordable Care Act Reporting for IRS Forms 1094 and 1095F
2017 ACA Order Form for Citv of South Bead
This order forth, effective July 3, 2017 constitutes a Services Agreement between AccordWare LLC and City of South Bend,
hereafter referred to as Company and Client respectively, for ACA Reporting Services. By executing this order form, Client
accepts the following:
Purpose
Client wishes to engage 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 Company to meet this obligation. Client will respond promptly to
questions and issues raised by 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 Company shall use same only as necessary to meet Client's reporting
obligations. 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 fitlfill 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.
2017 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 25
TBD
$750.00
& 1095-C
Per1095-C Form
* Postage is billed as an at cost pass through cost to employer
ADDITIONAL TERMS
Product Availability. 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, 2017 (the "Product Launch Date"); however, the ability to meet this Product Launch
Date depends upon the timely actions of the Client, 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 Company in
writing.
Billing, Billing of the Implementation or Annual Base fee will occur on or about December 1, 2017. Total
Reporting Service and Postage Fees under this order form will be billed on or about February I, 2018,
Term. This order form covers the reporting period for the 2017 calendar year. ("Full Agreement Term").
COSB Order Form 3 Confidential Page I of 4
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