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© Peak One Administration 2016 21 <br />BENEFIT PLAN COMPLIANCE SERVICES APPENDIX <br />The Client has established one or more employee benefit plans which are subject to various compliance <br />requirements under the Internal Revenue Code, ERISA or other applicable law. Client has engaged PSP to assist it <br />with the ministerial functions related to performing compliance requirements for the following employee benefit <br />plans: <br />A Code Section 125 Plan to allow eligible employees who make a proper election to pay for their <br />share of certain benefit plan coverage with pre-tax salary reductions (“Cafeteria Plan”). <br />A Flexible Spending Account to allow participants to be reimbursed for eligible medical expenses <br />(“FSA”). <br />A Code Section 105 health expense reimbursement plans (“HRA”) to allow participants to be <br />reimbursed for eligible medical expenses. <br />A Code Section 129 dependent care assistance plan to allow participants to be reimbursed for <br />eligible dependent care assistance expenses (“DCAP”.) <br />A Premium Only Section 125 Plan (“POP”). <br />A Health Savings Account (“HSA”). <br />A Parking/Mass Transit Fee Plan (“Transportation Plan”). <br />A Section 115 Plan (“Section 115 Plan”) <br />A Section 501(9)(c) Plan <br />(Collectively the selected plans are referred to in this Appendix as “Benefit Plans”). <br />PSP will provide assistance, designated below by Client, only with respect to the Benefits Plans selected above for <br />which PSP has provided the sample plan documentation or, if PSP’s sample plan documentation is not utilized, then <br />only such plans identified by Client and agreed to by PSP pursuant to separate written notice. <br />This Service Appendix is incorporated into and made a part of the Administrative Services Agreement (the <br />“Agreement”). The effective date of this Service Appendix is the effective date of the Agreement or if later, the date <br />that both parties have signed this Service Appendix as set forth below. The responsibilities of the parties set forth <br />in this Service Appendix are in addition to any responsibilities set forth in the Agreement. If there is a conflict <br />between this Service Appendix and the Agreement, the Agreement controls. <br />PSP and Client Responsibilities <br />The services PSP will perform pursuant to this Appendix are limited to those identified below as PSP responsibilities. <br />1.Forms 5500. <br />(a)PSP will assist Client in preparing the applicable Form 5500 for the: <br />i.FSA <br />ii.HRA <br />PSP will assist Client in preparing the applicable Form 5500 by providing, upon written <br />request from the Client, any information maintained in PSP’s database that is required <br />X <br />X <br />X <br />X <br />N/A <br />N/A