CY2015 1st Amendment 02/10/2016 •
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cinOrtt,fr -,N .3_ Amy HEAviLIN cpA
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% V.710, - - CLERK OF CIRCUIT COURT & COMPTROLLER
,� o:, �►\ ,g, y MQNRQE COUNTY,FLORIDA
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DATE: April 21, 2016
TO: Maria Fernandez-Gonzalez
Senior Benefits Administrator
FROM: Cheryl Robertson Executive Aide to the Clerk of Court& Comptroller 04
At the February 10, 2016 Board of County Commissioner's meeting the Board granted approval and
execution of the following Items:
C5 Approval of amendment to the Subscription Agreement with ,orxtime LLC co ,eying calendar
year 2015, in order to engage Worxtime LLC to direct mail IRS forms 1`095=C (required by IRS Sections
6055 and 6066 to confirm health insurance coverage) for all employees and retirees.
C6 Approval of a Service Agreement with Wo xtime-L-LC-coverin calendar year 2016, in order to
engage Worxtime to prepare and direct mail IRS forms 1095-C (required by IRS Sections 6055 and
6066 to confirm health insurance coverage)to all employees and retirees.
Attached is a duplicate original of the above-mentioned for your handling. Should you have any
questions please do not hesitate to contact this office.
cc: County Attorney
Financ
File f J 4 2-1'
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500 Whitehead Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663
3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fax:305-289-6025
88820 Overseas Highway,Plantation Key,FL 33070 Phone:852-7145 Fax:305-852-7146
AMENDMENT TO
SERVICE AGREEMENT
II
THIS AMENDMENT TO THE SERVICE AGREEMENT("Amendment")is entered into as of this I��
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day of , by and between WORXTIME LLC, a Georgia limited liability company("Worxtime")and
Monroe County Board of County Comissioners ("You,""Your"or"Customer"). Any defined terms used herein
that are not specifically defined herein shall have the same meaning as set forth in the Agreement.
WHEREAS,Worxtime and Customer entered into that certain Service Agreement,dated 29th of July,2015
("Agreement"),with respect to the Worxtime program and certain services;and
WHEREAS,Worxtime and Customer agree to amend the Agreement as more particularly set forth herein;
NOW THEREFORE, in consideration of the mutual promises and covenants contained herein and in the Agreement,
Worxtime and Customer hereby agree as follows:
1. Mailing of Forms 1095C. Worxtime agrees to mail 1095C forms to all benefit eligible employees
for calendar year 2015 and employees that have been offered coverage during calendar year
2015. The determination as which employees are to be mailed 1095C forms and to what address
such forms will be mailed shall be based on the data provided by You;
2. Monroe County Board of County Comissioners agrees to pay$3.00 per mailed 1095C form to
Worxtime, LLC for this service;
3. The Quantity is to be deteremined and will be deteremined after confirmation of Eligible
Employees.
4. Except as expressly amended hereby,all the remaining provisions of the Subscription
Agreement shall remain in full force and effect. o� a -ri
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The parties hereby agree and consent to the terms and conditions of these Amendments to- 9 -0 C
stated Subscription Agreement and acknowledge such by executing the Amendments below. P
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Executed by :<_- _ n
Customer: Monro• ou Board of County Accepted By: Worxtime LLC
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Signature: Signature: ,i.tz - Biel
Printed Name: Heather Carruthers Printed Name: Tearle D. Bagwell
Title: Mayor Title: Managing Partner
Date 4/a,/!CO Date
Signed: Signed:
1100 Simonton Street 7500 S. Memorial Pkwy
Address: Room 268 Address: Suite 211
Key West, FL 33040 Huntsvil_,AL 35802 - /
Approved b • FAINI
MONROE COUNTY ATTORNEY 0,V'
PROV D AS T Ft' r `-- � A ,
CYNTHIA L. HAL . .:. .i, ,.'.! MEAVIUN,CLERK
ASSIS ANT COUNTY ATTORNEY -
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