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STERLING 1000 Broadway, #250 ,t 800-617-4729 Oaklantl, CA 94607 ® wwwsterlinaadministrationxom ADMINISTRATION- Legal Employer Name: Tax I D #: 95-6000785 of Santa Ana Tax Year: 2023 Total Employees: 1203 PACKAGE SELECTED 0 Sterling: $4,000 Send Sterling your data in Excel format to populate the template for you. ❑ Basic: $3,000 Self -Service —you must populate the Sterling template yourself. ADDITIONAL SERVICES ❑ Control Groups: $1,000/per entity If you are unsure if you area controlled group, check with your CPA. Is information for all entities the same as the information for the parent company? ❑ Yes ❑ No *if no, separate renewal form required for each entity* 0 Print & Mail: $3.75/perform + $300/flat (for groups under 1,000 EEs from May -Dec) Copy of 1095 form mailed to the employee. *Please note E-filing costs are included in the package fees* ❑ Late Renewal: $750 Assessed on Renewal Applications submitted after 11/30/2023. TYPE OF ENTITY ❑ C Corporation ❑ Subchapter ❑ LLC/LLP n Government 1094/1095 FORM INFORMATION Is the employer an ALE? Do you have part time employees? Do you have seasonal employees? State of Organization or Incorporation: ❑ Educational Organization ❑ Partnership/ Sole ❑ Proprietorship Church Organization ❑ Non-profit Organization 0 Yes ❑ No 0 Yes ❑ No 0 Yes ❑ No CA CHOOSE YOUR 4980H AFFORDABILITY SAFE HARBOR ❑ Federal Poverty Line Safe Harbor If you offered employee only coverage that is no more than 9.12% of the Federal Poverty Guidelines, coverage is considered affordable. For 2023, if you offered coverage that did not cost an employee more than $103.28 per month for single coverage, this would be considered affordable. Always look at the employee contributions for the lowest cost plan. ❑ Rate of Pay Safe Harbor If you offered coverage that was no more than 9.12% of the employee's rate of pay at the time offered benefits (normally at the beginning of the plan year), this would be considered affordable. ❑� W2 Safe Harbor If you offered coverage that was no more than 9.12% of an employee's salary for employee only coverage, this would be considered affordable. The W2 amount would be obtained from box 1 in the 2023 W2. PARITY PERIOD LENGTH If an employee terminates from the company and is rehired at a later date, the employee wilt be considered anew hire after a break in service of 4 consecutive weeks (between 4 and 13 weeks).