HomeMy WebLinkAbout2019-11-04-J01C Transfer of Public Funds Agreement_IDHSAGENDA ITEM:
CITY OF WAUKEE, IOWA
CITY COUNCIL MEETING COMMUNICATION
MEETING DATE: November 4, 2019
AGENDA ITEM:Consideration of approval of a resolution approving Intergovernmental
Transfer (IGT) of Public Funds Agreement between the IA Department of
Human Services (IA DHS) and the City of Waukee
FORMAT:Consent Agenda
SYNOPSIS INCLUDING PRO & CON: The City of Waukee is participating in a program called
Ground Emergency Medical Transport (GEMT). GEMT is a supplemental
payment for transport of Medicaid patients. Supplemental payments come
from the Federal gov’t (CMS), the State of IA takes 40% and the remaining is
provided to the city to. This is a state wide program, available to publicly
funded EMS transport agencies. The IGT facilitates the transfer of funds
between the city and state.
FISCAL IMPACT INCLUDING COST/BENEFIT ANALYSIS: Fiscal impact is still being
analyzed. Currently IA Medicaid pays roughly $120 out of a $600 transport
bill. The GEMT program is intended to close the gap. Overall it will be a
positive impact to the revenue. The fire Dept. and finance are working on
extensive cost reports required by the state. There is no cost to the city to enter
this program.
COMMISSION/BOARD/COMMITTEE COMMENT:
STAFF REVIEW AND COMMENT: Staff recommends approval.
RECOMMENDATION: Approve the resolution.
ATTACHMENTS: I. Proposed Resolution
II. Agreement
PREPARED BY:Fire Chief Clint Robinson
REVIEWED BY:
PUBLIC NOTICE INFORMATION –
NAME OF PUBLICATION:
DATE OF PUBLICATION:
J1C
THE CITY OF WAUKEE, IOWA
RESOLUTION 19-
APPROVING INTERGOVERNMENTAL TRANSFER (IGT) OF PUBLIC FUNDS
AGREEMENT BETWEEN THE IA DEPARTMENT OF HUMAN SERVICES (IA DHS)
AND THE CITY OF WAUKEE
IN THE NAME AND BY THE AUTHORITY OF THE CITY OF WAUKEE, IOWA
WHEREAS, the City of Waukee, Iowa is a duly organized municipality within Dallas County;
AND,
WHEREAS, the City of Waukee participates in the Ground Emergency Medical Transport
(GEMT) program, which provides supplemental payment for the transport of Medicaid patients;
AND,
WHEREAS, the GEMT program is offered statewide to publicly funded emergency medical
service (EMS) transport agencies; AND,
WHEREAS, an Intergovernmental Transfer of Public Funds Agreement is proposed at no cost
to the City of Waukee in order to facilitate the transfer of GEMT funds between the City and
state.
NOW THEREFORE BE IT RESOLVED by the City of Waukee City Council in session this
4th day of November, 2019, that it hereby approves a Intergovernmental Transfer (IGT) of Public
Funds Agreement between the IA Department of Human Services (IA DHS) and the City of
Waukee.
____________________________
William F. Peard, Mayor
Attest:
___________________________________
Rebecca D. Schuett, City Clerk
RESULTS OF VOTE: AYE NAY ABSENT ABSTAIN
Anna Bergman
R. Charles Bottenberg
Courtney Clarke
Shelly Hughes
Larry R. Lyon
Updated October 14, 2019
INTERGOVERNMENTAL TRANSFER OF PUBLIC
FUNDS AGREEMENT BETWEEN
THE IOWA DEPARTMENT OF HUMAN SERVICES AND
Ground Emergency Medical Transportation Provider (GEMT Provider)
This Intergovernmental Transfer Agreement (Agreement) is entered into between the Iowa
Department of Human Services (IDHS) and the ground emergency medical transportation
(GEMT) Provider. It provides for an intergovernmental transfer of funds to the IDHS from the
GEMT Provider in order to provide the non-federal share of the reconciled cost reimbursement
amount for the uncompensated Medicaid cost associated with GEMT services.
The GEMT Provider is authorized by House File (HF) 2285 of the 2018 Iowa legislative
session to enter into and carry out an Intergovernmental Transfer (IGT) Agreement to transfer
funds through IGTs to the IDHS for use as the non-federal share of Medicaid expenditures.
AGREEMENT
1. GEMT Program Compliance. Attached hereto as Exhibit A is State Plan Amendment
IA-19-002 (SPA), which address the GEMT Program. The GEMT Provider shall at all
times comply with all requirements of the SPA.
2. Compliance with Provider Agreement and GEMT Program Eligibility. The GEMT
Provider’s Iowa Medicaid Provider Agreement is incorporated herein by reference. The
parties stipulate to the inclusion of any future amendments or replacement of any such
provider agreements by this reference. The GEMT Provider hereby represents, warrants
and covenants that is and at all relevant times will be an Eligible GEMT Provider as that
term is defined in the SPA. If at any time the GEMT Provider’s status changes such that
it is no longer an Eligible GEMT Provider, the GEMT Provider shall immediately notify
the IDHS.
3. Fund Transfer. The GEMT Provider agrees to transfer funds to IDHS at the times and
in the amounts determined in accordance with the following paragraphs of this
Agreement. The transfer shall be made prior to the payment by IDHS for the
uncompensated Medicaid cost associated with GEMT services. The GEMT Provider
will transfer funds to IDHS equivalent to the non-federal share of the payments to be
made upon notification by IDHS.
4. Funds Certification. The GEMT Provider shall certify that the funds transferred
qualify for federal financial participation (FFP) pursuant to 42 CFR part 433 subpart B,
and are not derived from impermissible sources such as recycled Medicaid payments,
federal money excluded from use as State match, impermissible taxes, and non-bona
fide provider-related donations. Impermissible sources do not include revenue received
from programs such as Medicare or Medicaid to the extent that the program revenue is
not obligated to the State as the source of funding.
City of Waukee
Updated October 14, 2019
5. Record Retention and Access. The parties agree that each shall maintain necessary
records and supporting documentation applicable to the uncompensated Medicaid cost
associated with GEMT services payments to assure that claims for total funds and
federal funds are in accordance with applicable federal requirements, including but not
limited to those record retention requirements set forth in the SPA. The parties agree to
make those records available to the parties and to any and all state or federal oversight
authorities immediately upon request.
6. Notices: Any written notice required by this Agreement shall be sent to:
For:
GEMT Provider
Printed Name:
Title:
Address:
E-mail address
For IDHS:
Printed Name:
Title:
Address:
E-mail address:
7. Repayment Obligation: In the event that any State and/or federal funds are deferred
and/or disallowed as a result of any audits or expended in violation of the laws applicable
to the expenditure of such funds, the GEMT Provider shall be liable to the Agency for the
full amount of any claim disallowed and for all related penalties incurred. The
requirements of this paragraph shall apply to the GEMT Provider as well as any
subcontractors of the GEMT Provider. To the extent that the GEMT Provider receives
City of Waukee
Clint Robinson
Fire Chief
230 W. Hickman Rd.
Waukee, IA 50263
crobinson@waukee.org
Updated October 14, 2019
payments that exceed the permissible amount allowed pursuant to the SPA, the parties
hereby deem the excess funds received by the GEMT Provider to be an “overpayment”
subject to return to the IDHS within 60 days pursuant to Section 2.5 of the Provider
Agreement.
8. Assignment: This Agreement is not assignable.
9. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement.
This Agreement is intended only to benefit the IDHS and the GEMT Provider.
10. Amendment: This Agreement may be modified at any time by the written agreement of
both parties.
11. Term & Termination: This Agreement covers the period beginning on or after July 1,
2019 and ending June 30, 2020. This Agreement may be canceled by either party after
giving thirty (30) days prior notice in writing to the other party. All obligations of the
parties incurred or existing under this Agreement as of the date of expiration or
termination survive the expiration or termination of the Agreement.
12. Execution: In consideration of the mutual covenants in this Agreement and for other
good and valuable consideration, the receipt, adequacy and legal sufficiency of which are
hereby acknowledged, the parties have entered into this Agreement and have caused their
duly authorized representatives to execute this Agreement.
GEMT Provider
Signature Date
Printed Name
Title
IOWA DEPARTMENT OF HUMAN SERVICES
Director Date
City of Waukee
William F. Peard
11/04/2019
Mayor
Updated October 14, 2019
Attachment A – Approved State Plan Amendment IA-19-002
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(G
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
0HWKRGVDQG6WDQGDUGVIRU(VWDEOLVKLQJ3D\PHQW5DWHVIRU2WKHU7\SHVRI&DUH
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
7KLVSURJUDPSURYLGHVVXSSOHPHQWDOSD\PHQWVIRUHOLJLEOH*URXQG(PHUJHQF\0HGLFDO
7UDQVSRUWDWLRQ*(07SURYLGHUVWKDWPHHWVSHFLILHGUHTXLUHPHQWVDQGSURYLGH*(07VHUYLFHV
WR,RZD0HGLFDLGPHPEHUV
6XSSOHPHQWDOSD\PHQWVSURYLGHGE\WKLVSURJUDPDUHDYDLODEOHRQO\IRUWKHXQFRPSHQVDWHGDQG
DOORZDEOHGLUHFWDQGLQGLUHFWFRVWVLQFXUUHGE\HOLJLEOH*(07SURYLGHUVZKLOHSURYLGLQJ*(07
VHUYLFHVWR,RZD0HGLFDLGPHPEHUV7KHVXSSOHPHQWDOSD\PHQWFRYHUVWKHJDSEHWZHHQWKH
HOLJLEOH*(07SURYLGHU¶VWRWDODOORZDEOHFRVWVIRUSURYLGLQJ*(07VHUYLFHVDVUHSRUWHGRQWKH
*(07VHUYLFHVFRVWUHSRUWDQGWKHDPRXQWRIWKHEDVHSD\PHQWPLOHDJHDQGDOORWKHUVRXUFHVRI
UHLPEXUVHPHQW
7KHVXSSOHPHQWDOSD\PHQWDPRXQWVVKDOOEHFDOFXODWHGDQQXDOO\RQDSURVSHFWLYHEDVLVDIWHUWKH
FRQFOXVLRQRIHDFKVWDWHILVFDO\HDU6)<3D\PHQWVVKDOOQRWEHSDLGDVLQGLYLGXDOLQFUHDVHVWR
FXUUHQWUHLPEXUVHPHQWUDWHVDVGHVFULEHGLQRWKHUSDUWVRIWKLVVWDWHSODQIRU*(07VHUYLFHV
7KLVVXSSOHPHQWDOSD\PHQWDSSOLHVRQO\WR,RZD0HGLFDLGVHUYLFHVUHQGHUHGWR,RZD0HGLFDLG
PHPEHUVE\HOLJLEOH*(07SURYLGHUVRQRUDIWHU-XO\
$ 'HILQLWLRQV
³'HSDUWPHQW´PHDQVWKH,RZD'HSDUWPHQWRI+XPDQ6HUYLFHV
³'LUHFW&RVWV´PHDQVDOOFRVWVWKDWFDQEHLGHQWLILHGVSHFLILFDOO\ZLWKSDUWLFXODUILQDO
FRVWREMHFWLYHVLQRUGHUWRPHHWDOOPHGLFDOWUDQVSRUWDWLRQPDQGDWHV
³6KDUHG'LUHFW&RVWV´DUHGLUHFWFRVWVWKDWFDQEHDOORFDWHGWRWZRRUPRUH
GHSDUWPHQWDOIXQFWLRQVRUFRVWREMHFWLYHVRQWKHEDVLVRIVKDUHGEHQHILWV
³,QGLUHFW&RVWV´PHDQVFRVWVIRUDFRPPRQRUMRLQWSXUSRVHEHQHILWWLQJPRUHWKDQ
RQHFRVWREMHFWLYHWKDWDUHDOORFDWHGWRHDFKEHQHILWLQJREMHFWLYHXVLQJDQDJHQF\
DSSURYHGLQGLUHFWUDWHRUDQDOORFDWLRQPHWKRGRORJ\,QGLUHFWFRVWVUDWHRUDOORFDWLRQ
PHWKRGRORJ\PXVWFRPSO\ZLWK&)53DUWDQG&06QRQLQVWLWXWLRQDO
UHLPEXUVHPHQWSROLF\
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(H
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
³(OLJLEOH*(073URYLGHU´PHDQVDSURYLGHUZKRLVHOLJLEOHWRUHFHLYHVXSSOHPHQWDO
UHLPEXUVHPHQWEHFDXVHLWPHHWVDOORIWKHIROORZLQJUHTXLUHPHQWVFRQWLQXRXVO\GXULQJ
WKHFODLPLQJSHULRG
D 3URYLGHV*URXQG(PHUJHQF\0HGLFDO7UDQVSRUWDWLRQVHUYLFHVWR,RZD
0HGLFDLGPHPEHUV
E ,WLVDSURYLGHUWKDWLVHQUROOHGDVDQ,RZD0HGLFDLGSURYLGHUIRUWKHSHULRG
EHLQJFODLPHG
F ,VRZQHGRURSHUDWHGE\DQHOLJLEOHJRYHUQPHQWDOHQWLW\WRLQFOXGHWKHVWDWHD
FLW\FRXQW\ILUHSURWHFWLRQGLVWULFWFRPPXQLW\VHUYLFHVGLVWULFWKHDOWKFDUH
GLVWULFWIHGHUDOO\UHFRJQL]HG,QGLDQWULEHRUDQ\XQLWRIJRYHUQPHQWDVGHILQHG
LQ&)56HF
³'U\5XQ´PHDQVDUXQWKDWGRHVQRWUHVXOWLQHLWKHUDWUDQVSRUWRUDGHOLYHU\RQVLWH
RI0HGLFDLGFRYHUHGVHUYLFHV
³*(077UDQVSRUW´PHDQV*(07VHUYLFHVSURYLGHGE\HOLJLEOH*(07SURYLGHUVWR
LQGLYLGXDOVDQGGRHVQRWLQFOXGHGU\UXQVDVGHILQHGLQ3DUDJUDSK$
³*(076HUYLFHV´PHDQVERWKWKHDFWRIWUDQVSRUWLQJDQLQGLYLGXDOIURPDQ\SRLQWRI
RULJLQWRWKHQHDUHVWPHGLFDOIDFLOLW\FDSDEOHRIPHHWLQJWKHHPHUJHQF\PHGLFDOQHHGV
RIWKHSDWLHQWDVZHOODVWKHDGYDQFHGOLPLWHGDGYDQFHDQGEDVLFOLIHVXSSRUW
VHUYLFHVSURYLGHGWRDQLQGLYLGXDOE\*(07SURYLGHUVEHIRUHRUGXULQJWKHDFWRI
WUDQVSRUWDWLRQ
D ³$GYDQFHG/LIH6XSSRUW´PHDQVVSHFLDOVHUYLFHVGHVLJQHGWRSURYLGH
GHILQLWLYHSUHKRVSLWDOHPHUJHQF\PHGLFDOFDUHLQFOXGLQJEXWQRWOLPLWHGWR
FDUGLRSXOPRQDU\UHVXVFLWDWLRQFDUGLDFPRQLWRULQJFDUGLDFGHILEULOODWLRQ
DGYDQFHGDLUZD\PDQDJHPHQWLQWUDYHQRXVWKHUDS\DGPLQLVWUDWLRQZLWKGUXJV
DQGRWKHUPHGLFLQDOSUHSDUDWLRQVDQGRWKHUVSHFLILHGWHFKQLTXHVDQG
SURFHGXUHV
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(I
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
E ³/LPLWHG$GYDQFHG/LIH6XSSRUW´PHDQVVSHFLDOVHUYLFHVWRSURYLGH
SUHKRVSLWDOHPHUJHQF\PHGLFDOFDUHOLPLWHGWRWHFKQLTXHVDQGSURFHGXUHVWKDW
H[FHHGEDVLFOLIHVXSSRUWEXWDUHOHVVWKDQDGYDQFHGOLIHVXSSRUWVHUYLFHV
F ³%DVLF/LIH6XSSRUW´PHDQVHPHUJHQF\ILUVWDLGDQGFDUGLRSXOPRQDU\
UHVXVFLWDWLRQSURFHGXUHVWRPDLQWDLQOLIHZLWKRXWLQYDVLYHWHFKQLTXHV
³6HUYLFH3HULRG´PHDQVWKHSHULRGIURP-XO\WKURXJK-XQHRIHDFK6)<
³6KLIW´PHDQVDVWDQGDUGSHULRGRIWLPHDVVLJQHGIRUDFRPSOHWHF\FOHRIZRUNDVVHW
E\HDFKHOLJLEOH*(07SURYLGHU7KHQXPEHURIKRXUVLQDVKLIWPD\YDU\E\*(07
SURYLGHUEXWZLOOEHFRQVLVWHQWWRHDFK*(07SURYLGHU
% 6XSSOHPHQWDO5HLPEXUVHPHQW0HWKRGRORJ\±*HQHUDO3URYLVLRQV
&RPSXWDWLRQRIDOORZDEOHFRVWVDQGWKHLUDOORFDWLRQPHWKRGRORJ\PXVWEHGHWHUPLQHG
LQDFFRUGDQFHZLWK0HGLFDLGFRVWSULQFLSOHVDW&)53DUWZKLFKHVWDEOLVK
SULQFLSOHVDQGVWDQGDUGVIRUGHWHUPLQLQJDOORZDEOHFRVWVDQGWKHPHWKRGRORJ\IRU
DOORFDWLQJDQGDSSRUWLRQLQJWKRVHH[SHQVHVWRWKH,RZD0HGLFDLGSURJUDPH[FHSWDV
H[SUHVVO\PRGLILHGEHORZ
,RZD0HGLFDLGEDVHSD\PHQWVWRWKH*(07SURYLGHUVIRUSURYLGLQJ*(07VHUYLFHV
DUHGHULYHGIURPWKH$PEXODQFHSURYLGHUIHHVFKHGXOHHVWDEOLVKHGIRU
UHLPEXUVHPHQWVSD\DEOHE\WKH,RZD0HGLFDLGSURJUDPE\SURFHGXUHFRGH7KHEDVH
SD\PHQWVIRUWKHVHHOLJLEOH*(07SURYLGHUVDUHIHHIRUVHUYLFH))6SD\PHQWV7KH
SULPDU\VRXUFHRISDLGFODLPVGDWDDQGRWKHU,RZD0HGLFDLGUHLPEXUVHPHQWVLVWKH
,RZD0HGLFDLG0DQDJHPHQW,QIRUPDWLRQ6\VWHP,$00,67KHQXPEHURISDLG
,RZD0HGLFDLG))6*(07WUDQVSRUWVLVGHULYHGIURPDQGVXSSRUWHGE\WKH,$00,6
UHSRUWVIRUVHUYLFHVGXULQJWKHDSSOLFDEOHVHUYLFHSHULRG
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(J
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
7KHWRWDOXQFRPSHQVDWHGFDUHFRVWVRIHDFKHOLJLEOH*(07SURYLGHUDYDLODEOHWREH
UHLPEXUVHGXQGHUWKLVVXSSOHPHQWDOSD\PHQWSURJUDPZLOOHTXDOWKHVKRUWIDOO
UHVXOWLQJIURPWKHDOORZDEOHFRVWVGHWHUPLQHGXVLQJWKH&RVW'HWHUPLQDWLRQ3URWRFROV
6HFWLRQ&IRUHDFKHOLJLEOH*(07SURYLGHUUHQGHULQJ*(07VHUYLFHVWR,RZD
0HGLFDLGPHPEHUVQHWRIWKHDPRXQWVUHFHLYHGDQGSD\DEOHIURPWKH,RZD0HGLFDLG
SURJUDPDQGDOORWKHUVRXUFHVRIUHLPEXUVHPHQWIRU*(07VHUYLFHVSURYLGHGWR,RZD
0HGLFDLGPHPEHUV,IWKHHOLJLEOH*(07SURYLGHUVGRQRWKDYHDQ\XQFRPSHQVDWHG
FDUHFRVWVWKHQWKHSURYLGHUZLOOQRWUHFHLYHVXSSOHPHQWDOUHLPEXUVHPHQWXQGHUWKLV
VXSSOHPHQWDOSD\PHQWSURJUDP
7KH,RZD0HGLFDLGVXSSOHPHQWDOSD\PHQWXQGHUWKLVVHJPHQWDUHWKHXQFRPSHQVDWHG
FDUHFRVWVIRU*(07VHUYLFHVSURYLGHGE\HOLJLEOH*(07SURYLGHUVWR,RZD
0HGLFDLGPHPEHUVDVGHWHUPLQHGE\WKH3URVSHFWLYH6XSSOHPHQWDO3D\PHQW$PRXQW
6HFWLRQ'
& &RVW'HWHUPLQDWLRQ3URWRFROV
$QHOLJLEOH*(07SURYLGHU¶VVSHFLILFDOORZDEOHFRVWSHU*(07WUDQVSRUWUDWHZLOO
EHFDOFXODWHGEDVHGRQWKHSURYLGHU¶VDXGLWHGILQDQFLDOGDWDUHSRUWHGRQWKH*(07
VHUYLFHVFRVWUHSRUW7KHSHU*(07WUDQVSRUWFRVWUDWHZLOOEHWKHVXPRIDFWXDO
DOORZDEOHGLUHFWVKDUHGGLUHFWDQGLQGLUHFWFRVWVRISURYLGLQJ*(07VHUYLFHV
H[FOXGLQJFRVWDVVRFLDWHGZLWKGU\UXQVDVGHILQHGLQ3DUDJUDSK$DQGUXQV
ZKHUHD0HGLFDLGFRYHUHGVHUYLFHZDVGHOLYHUHGEXWQRWUDQVSRUWRFFXUUHG
GLYLGHGE\WKHDFWXDOQXPEHURI*(07WUDQVSRUWVLQFOXGLQJGU\UXQVDVGHILQHGLQ
3DUDJUDSK$DQGUXQVZKHUHD0HGLFDLGFRYHUHGVHUYLFHZDVGHOLYHUHGEXWQR
WUDQVSRUWRFFXUUHGSURYLGHGIRUWKHDSSOLFDEOHVHUYLFHSHULRG
D 'LUHFWFRVWVIRUSURYLGLQJ*(07VHUYLFHVLQFOXGHRQO\WKHXQDOORFDWHGSD\UROO
FRVWVIRUWKHVKLIWVLQZKLFKSHUVRQQHOGHGLFDWHSHUFHQWRIWKHLUWLPHWR
SURYLGLQJ*(07VHUYLFHVPHGLFDOHTXLSPHQWDQGVXSSOLHVDQGRWKHUFRVWV
GLUHFWO\UHODWHGWRWKHGHOLYHU\RIFRYHUHGVHUYLFHVVXFKDVILUVWOLQH
VXSHUYLVLRQPDWHULDOVDQGVXSSOLHVSURIHVVLRQDODQGFRQWUDFWHGVHUYLFHV
FDSLWDORXWOD\WUDYHODQGWUDLQLQJ7KHVHFRVWVPXVWEHLQFRPSOLDQFHZLWK
0HGLFDLGQRQLQVWLWXWLRQDOUHLPEXUVHPHQWSROLFLHVDQGDUHGLUHFWO\
DWWULEXWDEOHWRWKHSURYLVLRQRIWKH*(07VHUYLFHV
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(K
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
E 6KDUHGGLUHFWFRVWVIRU*(07VHUYLFHVPXVWEHDOORFDWHGIRUSHUVRQQHOFDSLWDO
RXWOD\DQGRWKHUFRVWVVXFKDVPHGLFDOVXSSOLHVSURIHVVLRQDODQGFRQWUDFWHG
VHUYLFHVWUDLQLQJDQGWUDYHO7KHSHUVRQQHOFRVWVZLOOEHDOORFDWHGEDVHGRQD
SHUFHQWDJHRIWRWDOKRXUVORJJHGSHUIRUPLQJ*(07VHUYLFHVDFWLYLWLHVYHUVXV
RWKHUVHUYLFHDFWLYLWLHV7KHFDSLWDODQGRWKHUVKDUHGGLUHFWFRVWVZLOOEH
DOORFDWHGEDVHGRQWKHSHUFHQWDJHRIWRWDOFDOOYROXPH
F ,QGLUHFWFRVWVDUHGHWHUPLQHGE\DSSO\LQJWKHFRJQL]DQWDJHQF\VSHFLILF
DSSURYHGLQGLUHFWFRVWUDWHWRLWVWRWDOGLUHFWFRVWV3DUDJUDSK&DRUGHULYHG
IURPSURYLGHU¶VDSSURYHGFRVWDOORFDWLRQSODQ(OLJLEOH*(07SURYLGHUVWKDW
GRQRWKDYHDFRJQL]DQWDJHQF\DSSURYHGLQGLUHFWFRVWUDWHRUDSSURYHGFRVW
DOORFDWLRQSODQWKHFRVWVDQGUHODWHGEDVLVXVHGWRGHWHUPLQHWKHDOORFDWHG
LQGLUHFWFRVWVPXVWEHLQFRPSOLDQFHZLWK0HGLFDLGFRVWSULQFLSOHVVSHFLILHG
DW&)53DUW
G 7KH*(07SURYLGHUVSHFLILFSHU*(07WUDQVSRUWFRVWUDWHLVFDOFXODWHGE\
GLYLGLQJWKHWRWDOQHW*(07VHUYLFHVDOORZDEOHFRVWV3DUDJUDSK&D&E
DQG&FRIWKHVSHFLILFSURYLGHUE\WKHWRWDOQXPEHURI*(07WUDQVSRUWV
SURYLGHGE\WKHSURYLGHUIRUWKHDSSOLFDEOHVHUYLFHSHULRG
' 3URVSHFWLYH6XSSOHPHQWDO3D\PHQW$PRXQW
7KH'HSDUWPHQWZLOOFDOFXODWHDQQXDOSURVSHFWLYHVXSSOHPHQWDOSD\PHQWDPRXQWVIRU
HOLJLEOH*(07SURYLGHURQDSHU*(07WUDQVSRUWEDVLV7KHSHU*(07WUDQVSRUW
SURVSHFWLYHVXSSOHPHQWDOSD\PHQWDPRXQWIRUHDFKSURYLGHULVEDVHGRQWKH
SURYLGHU¶VFRPSOHWHGDQQXDOFRVWUHSRUWLQWKHIRUPDWSUHVFULEHGE\WKH'HSDUWPHQW
IRUWKHDSSOLFDEOHFRVWUHSRUWLQJ\HDU7KH'HSDUWPHQWZLOOPDNHDGMXVWPHQWVWRWKH
DVILOHGFRVWUHSRUWEDVHGRQWKHUHVXOWVRIWKHPRVWUHFHQWO\UHWULHYHG,$00,6
UHSRUW
(DFKHOLJLEOH*(07SURYLGHUPXVWFRPSXWHWKHDQQXDOFRVWLQDFFRUGDQFHZLWKWKH
&RVW'HWHUPLQDWLRQ3URWRFROV6HFWLRQ&DQGPXVWVXEPLWWKHFRPSOHWHGDQQXDODV
ILOHGFRVWUHSRUWWRWKH'HSDUWPHQWILYHPRQWKVDIWHUWKHFORVHRIWKHVHUYLFH
SHULRG
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(L
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
7KHSURVSHFWLYHVXSSOHPHQWDOSD\PHQWDPRXQWLVFDOFXODWHGE\VXEWUDFWLQJIURP
,RZD0HGLFDLG¶VSRUWLRQRIWKHWRWDO*(07DOORZDEOHFRVWV3DUDJUDSK&IURPWKH
DVILOHGFRVWUHSRUWDGMXVWHGE\WKH'HSDUWPHQW3DUDJUDSK'WKHWRWDO,RZD
0HGLFDLGEDVHSD\PHQWV3DUDJUDSK%DQGRWKHUSD\PHQWVVXFKDV,RZD0HGLFDLG
FRSD\PHQWVUHFHLYHGE\WKHSURYLGHUVIRUSURYLGLQJ*(07VHUYLFHVWR,RZD
0HGLFDLGPHPEHUV7KHUHVXOWRIWKLVFDOFXODWLRQLVWKHXQFRPSHQVDWHGFDUHFRVWVIRU
*(07VHUYLFHVSURYLGHGWR,RZD0HGLFDLGPHPEHUV
7KHUHVXOWLQ3DUDJUDSK'LVGLYLGHGE\WKH,RZD0HGLFDLG*(07WUDQVSRUWV
LQFOXGLQJGU\UXQVDVGHILQHGLQ3DUDJUDSK$IURPWKHDVILOHGFRVWUHSRUWDGMXVWHG
E\WKH'HSDUWPHQWWRFDOFXODWHWKHSHU*(07VHUYLFHVSURVSHFWLYHVXSSOHPHQWDO
SD\PHQWDPRXQW7KLVDPRXQWZLOOEHSDLGSURVSHFWLYHO\LQDGGLWLRQWRWKH,RZD
0HGLFDLGEDVHSD\PHQWV3DUDJUDSK%RQDFODLPE\FODLPEDVLV
7KHSURVSHFWLYHVXSSOHPHQWDOSD\PHQWDPRXQWZLOOEHXSGDWHGWKHIROORZLQJ-XO\
DQGHYHU\\HDUWKHUHDIWHUIROORZLQJVXEPLVVLRQDQGUHYLHZRIWKHFRVWUHSRUW
6SHFLILFDOO\WKHSULRU\HDU¶VXQFRPSHQVDWHGFDUHDPRXQWSHU0HGLFDLGWUDQVSRUWZLOO
EHSDLGDVDQDGMXVWPHQWWRWKHIROORZLQJ\HDU¶VEDVHUDWH
( (OLJLEOH*(073URYLGHU5HSRUWLQJ5HTXLUHPHQWV
(OLJLEOH*(07SURYLGHUVVKDOO
6XEPLWWKH*(07VHUYLFHVFRVWUHSRUWQRODWHUWKDQILYHPRQWKVDIWHUWKHFORVHRI
WKH&<XQOHVVDSURYLGHUKDVPDGHDZULWWHQUHTXHVWIRUDQH[WHQVLRQDQGVXFK
UHTXHVWLVJUDQWHGE\WKH'HSDUWPHQW
3URYLGHVXSSRUWLQJGRFXPHQWDWLRQWRVHUYHDVHYLGHQFHVXSSRUWLQJLQIRUPDWLRQRQWKH
VXEPLWWHGFRVWUHSRUWDQGWKHFRVWGHWHUPLQDWLRQDVVSHFLILHGE\WKH'HSDUWPHQW
.HHSPDLQWDLQDQGKDYHUHDGLO\UHWULHYDEOHVXFKUHFRUGVDVVSHFLILHGE\WKH
'HSDUWPHQWWRIXOO\GLVFORVHUHLPEXUVHPHQWDPRXQWVWRZKLFKWKHHOLJLEOH
JRYHUQPHQWHQWLW\LVHQWLWOHGDQGDQ\RWKHUUHFRUGVUHTXLUHGE\&06
-XO\
-XO\
$WWDFKPHQW%
5HYLVHG6XEPLVVLRQ3$*(M
6WDWH7HUULWRU\,2:$
6WDWH3ODQ71,$ (IIHFWLYH
6XSHUVHGHG711(: $SSURYHG
6XSSOHPHQWDOSD\PHQWIRUSXEOLFO\RZQHGRURSHUDWHGJURXQGHPHUJHQF\PHGLFDO
WUDQVSRUWDWLRQSURYLGHUV
&RPSO\ZLWKWKHDOORZDEOHFRVWUHTXLUHPHQWVSURYLGHGLQ&)53DUWDQG
0HGLFDLGQRQLQVWLWXWLRQDOUHLPEXUVHPHQWSROLF\
) 'HSDUWPHQW5HVSRQVLELOLWLHV
7KH'HSDUWPHQWZLOOVXEPLWWR&06FODLPVIRU*(07VHUYLFHVWKDWDUHDOORZDEOH
DQGLQFRPSOLDQFHZLWKIHGHUDOODZVDQGUHJXODWLRQVDQG0HGLFDLGQRQLQVWLWXWLRQDO
UHLPEXUVHPHQWSROLF\
7KH'HSDUWPHQWZLOORQDQDQQXDOEDVLVVXEPLWDQ\QHFHVVDU\PDWHULDOVWRWKH
IHGHUDOJRYHUQPHQWWRSURYLGHDVVXUDQFHVWKDWFODLPVZLOOLQFOXGHRQO\WKRVH
H[SHQGLWXUHVWKDWDUHDOORZDEOHXQGHUIHGHUDOODZ
7KH'HSDUWPHQWPD\FRQGXFWRQVLWHDXGLWVDVQHFHVVDU\DQGZLOOFRPSOHWHWKHDXGLW
ZLWKLQWZR\HDUVRIWKHSRVWPDUNGDWHRIWKHDFFHSWHGFRVWUHSRUW
-XO\
-XO\