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DocuSign Envelope ID: CFCE3443-EF37-4FD4-8DCD-D85D559F77AE <br />✓ Fund Rollover (FSA Carryover, HRA and Commuter) <br />✓ Investment Options (HSA only) <br />✓ Participant Call Center Support - Domestically Based <br />✓ Participant Communications & Alerts (Real Time) <br />• Communications are in electronic format <br />• Account Statements are emailed monthly <br />• Year-end tax statements (HSA only) <br />✓ Participant Mobile App <br />✓ Plan Document and Summary Plan Descriptions (fees apply if such <br />documentation is not required for Plan compliance) <br />Included Annual Services List: <br />✓ Non-discrimination Testing (NDT) (provided such testing is required for compliance <br />of spending accounts administered by Igoe) <br />✓ Open Enrollment Processing' <br />Billable Services List — Not Included <br />This list outlines services that are not included in the Monthly Participation Rate. Fees based <br />on time and ability will be presented to the Client by means of a written proposal (statement of <br />work) and must be agreed to before such services are provided. Postage expenses are <br />calculated using the official Federal USPS postal rate as of the time of the mailing. <br />✓ Benefit Cards <br />• Cards in excess of the 2 card per participant limit: $5.00 per <br />• Lost/Stolen/Damaged Replacement Cards: $5.00 per <br />✓ Benefit Fair and/or Open Enrollment Meeting Attendance <br />• $300 per day + travel <br />This fee is waived for clients within 100 miles of Igoe's San Diego based corporate <br />facility. Igoe's attendance is subject to associate availability. <br />✓ Banking Fees <br />• ACH Rejection -Client: $50.00 per each rejected client ACH <br />• Direct Deposit Rejection -Participant: $15.00 per each returned participant <br />ACH <br />• Reimbursement Reissuance: $10.00 per each reissued reimbursement (ACH <br />or manual check) <br />• Stop Payment: $15.00 per stop payment (fee only applies to manually issued <br />710anual Enrollment Processing fees will apply if election data is provided in a manual format and/or after the data submission detail outlined in <br />the Annual Open Enrollment Guide. Changes made to system configuration to accommodate amended benefit offerings are subject to System <br />Re -configuration fees. <br />/GCE <br />City of Santa Ana Spending Account Administrative Services Agreement <br />Client Initials: <br />PEPM17 <br />Page Is <br />