2018-205-E Health - Elavon credit card fees

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DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 REPORTING TOOLS CONVENIENCE FEE SERVICES PROGRAMS ® MCP ONLY OR ❑ MCP WITH OCM ► MONTHLY FEE $ 0SETUP FEE $ /# USERS /SET UP TYPE (CHECK ONE) [I MID C1 CHN ❑ ACS ►MONTHLY FEE $ /SET UP FEE $ /REMOTE ID OTHER VAS CONVENIENCE FEE FUNDING MODEL (CHECK ONE): FO Dynamic Currency Conversion (DCC): ❑ COMPANY MANAGED CONVENIENCE FEE' DCC Conversion Rate: % DCC Rebate: % Annual DCC Registration Fee: $ DCC Exchange Rate Source: US Bank CONVENIENCE FEE AND GOVERNMENT /PUBLIC INSTITUTION SERVICE FEES (GPISF) CONVENIENCE FEE SERVICES PROGRAMS GPISF SERVICES PROGRAMS CHECK ALL THAT APPLY, BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENTS: ❑ COMPANY - MANAGED SERVICE FEE' CONVENIENCE FEE FUNDING MODEL (CHECK ONE): ❑ COMPANY- MANAGED WITH ELAVON POS DEVICES /SERVICE FEE TERMINALS4 ❑ COMPANY MANAGED CONVENIENCE FEE' ❑ ELAVON- MANAGED SERVICE FEES ❑ ELAVON MANAGED CONVENIENCE FEE' CARD ACCEPTANCE (CHECK ALL THAT APPLY): PAYMENT TRANSACTION TYPES ❑ POINT OF SALE ❑ INTERNET ❑ CREDIT (CHECK ALL THAT APPLY): ❑ IVR ❑ OTHER: ❑ VISA ❑ MASTERCARD ❑ DISCOVER GPISF SERVICES PROGRAMS (CHECK ALL THAT APPLY, BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENTS: ❑ SIGNATURE DEBIT (CHECK ALL THAT APPLY): ❑ MASTERCARD GOVERNMENT AND EDUCATION PAYMENT PROGRAM ❑ VISA ❑ MASTERCARD ❑ DISCOVER ❑ PIN -BASED DEBIT ❑ ACH (VIA ELECTRONIC CHECK SERVICES) ELAVON PRODUCT SUPPORTING ELAVON- MANAGED CONVENIENCE FEE ASSESSMENT TO BE USED BY COMPANY (CHECK ALL THAT APPLY): ❑ COMPANY PROPRIETARY SOLUTION OR SERVICE PROVIDER ❑ OTHER: CONVENIENCE FEE PRICING: CONVENIENCE FLAT FEE AMOUNT: CONVENIENCE FEE %: (MASTERCARD, DISCOVER & ACH PROGRAMS ONLY) IMPLEMENTATION FEE (IF APPLICABLE): ❑ VISA GOVERNMENT AND EDUCATION PAYMENT PROGRAM TRANSACTION TYPES: ❑ FEDERAL INCOME TAX ❑ GOVERNMENT FEES ❑ STATE INCOME TAX ❑ REAL ESTATE PROPERTY TAX ❑ BUSINESS TAX ❑ OTHER TAX ❑ TUITION ❑ OTHER EDUCATION EXPENSES PAYMENT TYPES FOR GPISF ASSESSMENT (NOT ALL PAYMENT TYPES ARE SUPPORTED FOR ALL PROGRAMS)(CHECK ALL THAT APPLY. BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENT): ❑ CREDIT — (CHECK ALL THAT APPLY): ❑ VISA — ELIGIBLE MCCS: 8211, 8220, 8244, 8249, 9211, 9222, 9311, 9399 ❑ MASTERCARD - ELIGIBLE MCCS: 8211, 8220, 8299, 9211, 9222, 9223, 9311, 9399, 9402 ❑ DISCOVER (AVAILABLE IF ELAVON- ACQUIRED) ❑ SIGNATURE DEBIT - (CHECK ALL THAT APPLY) ❑ VISA— ELIGIBLE MCCS: 8211, 8220, 8244, 8249, 9211, 9222, 9311, 9399 ❑ MASTERCARD — ELIGIBLE MCCS: 8211, 8220, 8299, 9211, 9222, 9223, 9311, 9399, 9402 ❑ DISCOVER (AVAILABLE IF ELAVON- ACQUIRED) ❑ ACH (VIA ELECTRONIC CHECK SERVICES) ELAVON PRODUCT SUPPORTING GPISF ASSESSMENT TO BE USED BY COMPANY (CHECK ALL THAT APPLY): ❑ SERVICE FEE TERMINAL ❑ COMPANY PROPRIETARY SOLUTION OR SERVICE PROVIDER ❑ SAFE -T SERVICES (ADDITIONAL ENROLLMENTFORM REQUIRED) ❑ OTHER: GPISF PRICING: CREDIT CARD SERVICE FEE: % OR $ SIGNATURE DEBIT SERVICE FEE: % OR $ ACH (VIA ELECTRONIC CHECK SERVICES): $ IMPLEMENTATION FEE (IF APPLICABLE): $ I "Company- Managed" Convenience Fee means that Company establishes the amount of the Convenience Fee (subject to the requirements of the Agreement and applicable Payment Network Regulations) and retains the Convenience Fee. Company pays Elavon the per transaction fees as set forth in this application to the Agreement for all Convenience Fee Transactions. 2 "Elavon- Managed" Convenience Fee means that Elavon establishes the amount of the Convenience Fee and retains the Convenience Fee in lieu of Company's obligation to pay Elavon the per transaction fees as set forth in this application to the Agreement for Convenience Fee Transactions. The Convenience Fee is still charged by Company and included in the overall transaction amount charged to the Cardholder. I "Company- Managed" Service Fee means that Company establishes the amount of the GPISF, programs its POS Devices to assess the GPISF, and retains the GPISF (subject to the requirements of the Agreement and applicable Payment Network Regulations). Company pays Elavon the per transaction fees as set forth in this application for all GPISF Transactions. 4 "Company- Managed with Elavon POS Devices /Service Fee Terminals" means that Elavon programs the POS Devices to assess the GPISF established by Company and Company retains the GPISF. Company pays Elavon the per transaction fees as set forth in this application to the Agreement for all GPISF Transactions. I "Elavon- Managed" Service Fee means that Elavon establishes the amount of the GPISF, and Elavon charges and retains the GPISF in lieu of Company's obligation to pay Elavon the per transaction fees and Safe -T Services fees (if Safe -T is chosen above) for GPISF Transactions. 4 USA- GOV -ELV -021 E