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r�� +kism tNslS"rtY sr� r �, �" i�Cd* cM�ir}Yn-3 oak irx�p ry�in�.. tl R ncs a rrv+F w r r I fj S � v� :ar ma t ui '. '.-r i'<'n�13E ik. lY.1 + ,, �� 9 .',�#+�Ji"`�'7 ';,:n,5fx. ila'k �."��'.u9Fn�1 }��i�V��f�1��i� r]"NU Nirl�„ Mom 4.0+ mr%. a, i rn. ❑ TASC HIPAA Compliance Services PRICING I • No set -Up Fee NOTE: Plan wilt begin on the first of the month in which application is received INFO: • Annual Admin Fee—flat rate (due now) i 111 • Annual Renewal Fee (billed outomaticollv) ADMINONLY:TASCHIPAA- SpecialInstructions: .p`m' wi f��'�? rmt else �R irr��err r°!�n°W�'�J�r?��k i+, 1 YrI FM1' a a. .5�ei.1.tre�ir+.'.u'mrftr>`�tr�f.sk..s�ix�aru �.r ,`�iap,.t.Sde�.n«�u�kar7 E7ii+eA11.�}kl�.0 r?�ii�d. 4� { .... ,01141Nawr 3�ii Mu..ail1... • Set -Up Fee (due now) ❑ TASC GiveBack (Workplace Giving Administration) PRICING ! • Admin Fee - per participant, per month INFO::. • Monthly Maintenance Fee Annual Renewal Fee PUA I' F611 ION Number of Eligible Employees: "Yf4Yi1 yry`"""` Payroll/Funding Cycle (select one): ❑ Weekly 0 Bl -Weekly p Semi -Monthly 0 Monthly ❑ Other: # Contributions in 12 -mo Plan Year:- ParticipantContributionschedule: Contribution dates may or may not be the same date as payroll dates: the ed Estimated Plan ate of Receipt chedule eipt(Ebelowfor 1" Contribution: ,_)_/_ 2°a Contribution ` _f_f_ Last Contribution: the Estimated Date of Receipt (EDR)1 First Year Administration to begin: first day of: _/_ mo/yr)Completed Plan Applications mustbe received by the 15th of the month prior to this start date. Company Match: 0 . _,......__.. ,..._ to _ ximum.Matc for _ -....bell .. _ No ❑Yes if Yes enter Maximum Match for each below: -Per Employee, Per Year: $ Per Payroll $ 1 Enrollment Bonus: ❑ No ❑ Yes if Yes, enter Company. Enrollment Bonus amount: $ Hold a Fundraiser: 0 No 0 Yes fCOmoonv fundraiser or featured emofovee fundralsarl This Section defines the method that your Plan will utilize to make payroll and payroll matching (as applicable) payments to TASC. Any payments described in this Section are In addition to the fees due under PART 3 (Fees). The preferred method of payment is through an Auto ACH where TASC Initiates submission of yourfee payment via ACH. To start this process: (1) choose which ACH process you want below, (2) verify your Expected Date of Receipt (EDR), and (3) provide ourbanklnformation: (1) I 0 TASC ACH (default): TASC Initiates funding payment via ACH on the EDR. 0 Client MyTASC Funding: Client Initiates funding payment via MyTASC on or before the EDR. Note: Under this option, TASC will use your Account and Routing Numbers to post any unpaid funding amounts that are one (1) business day past the due date. Also, addltlonal annual feewlll apply if ACH is not elected ($10.00 per payroll). - (2) Expected Date of Receipt EDR is the date that TASC will pull an Auto ACH from your designated account and apply the payroll contributions to your (EDR): - participants account(s). This may or may not be the same date as the participant's payroll data. The EDR date is the payroll contribution schedule Indicated above for each payroll cycle. (3) : Bank Information: ❑ Use same ACH info from Part 4 of this Application ❑ Use different ACH information as per below: Financial Institution Name: State: Bank Routing Number IS digits): Checking Account #: ADMIN ONLY: TASC GiveBacl<- Special Instructions: -- Page 11 Empoyerinitial '. �� '41VASC TU9913-010117 ---- --