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Org. Agency CodeDateRequisition No.Comptroller's
Contract No.:
PS65669Commodity Group No.:
79008Work Order No.Originating Agency:EVT Program #(s) (from Part 3 of Form EVTA-1):VENDOR:
American Express Government SRG
Merchant Services
PO Box 53773
Phoenix, AZ 85072
With an electronic copy to:
American Express
Attn: John L. Cavanagh
John.L.Cavanagh1@aexp.com
SHIP TO:Unless otherwise indicated, all prices are F.O.B. Destination
DISCOUNT TERMS
Item No.Description of ServicesStart DateEnd Date*Estimated Annual
Cost**Estimated
Total Cost
(entire term)Provide Electronic Value Transfer Services in accordance with attached EVTA-2, Work Order *Note: End date cannot extend beyond 10/31/2016.
**Note: The annual cost should relate to the remaining fiscal year period
This EVTA Work Order is effective and binding when it contains the approvals from the Electronic Value Transfer Administrator, is signed by the Originating Agency and is submitted with a valid Purchase Order and is transmitted to the Contractor. Notwithstanding the foregoing, unique terms and conditions added by the Authorized User in section 6 pursuant to the authority in Appendix B 40 or 44, must have Contractors written approval before the Work Order takes effect and becomes binding. By signing this Form, authorized User agrees to be bound by the terms and conditions of contract PS65669, except as modified by sections 4, 5 and 6 of this Form.
________________________________________
APPROVED
Electronic Value Transfer Administrator
(New York State Department of Taxation and Finance)Originating Agency SignatureSignature:Name:Title:Date: The State of New York is an Equal Opportunity/Affirmative Action Employer.
[This section is primarily for NYS Agencies]
Exemption from Taxes
All EVT orders from New York State agencies are exempt from certain federal taxes, and New York State and local sales taxes pursuant to Articles 28 and 29 of the New York State Tax Law. This Form EVTA-2 Work Order must be accepted in lieu of an exemption certificate; the vendor must retain a copy of this work order to prove that the sale was exempt. Do not include taxes from which the State is exempt when submitting invoices.
Introduction
Form EVTA-2, Work Order, in conjunction with a valid Purchase Order, authorizes Contractor to initiate reimbursable activities, associated with providing the specific financial processing services for the implementation of the Authorized Users Electronic Value Transfer program. All Authorized Users must use this work order form as the formal document to commence reimbursable services. All Authorized Users must provide AMEX with an approved copy of Part 3 of Form EVTA-1, Program Plan Application, indicating authorization to implement an EVT program before services requested on this document can be officially started. For more information regarding Form EVTA-1, Program Plan Application, visit the Electronic Value Transfer Administrators Web site (HYPERLINK "http://www.tax.ny.gov/evta"www.tax.ny.gov/evta).
Using the OGS EVT Contract with Contractor
The following steps describe the process for using the OGS EVT Contract with Contractor. For more information refer to OGS Contract Award Notice available from their Web site (HYPERLINK "http://www.ogs.ny.gov/purchase"www.ogs.ny.gov/purchase). Note: The following three steps all apply Authorized Users;
Step 1: Complete this Form EVTA-2, Work Order.
An Authorized User, in conjunction with Contractor, must complete this Form EVTA-2, Work Order to identify the specific services it intends to procure under the contract. In completing this work order, Authorized Users will also be identifying their programs technical details, projected costs and any unique terms and conditions. Instructions for completing this form are found in the How to Complete Form EVTA-2, American Express Work Order section on page 3.
Step 2: Obtain Contractor approval for unique terms or conditions.
Any terms or conditions included in this Form EVTA-2, that are not provided for in the Contract, shall be reviewed and approved in writing by Contractor. Section 6, Unique Terms or Conditions, of this form must be used to identify any unique terms or conditions. Contractor shall approve any such unique terms or conditions by completing the signature lines at the end of Section 6 of this form. If Merchant has local laws that impact payment processing, such law must be identified and presented in this section.
Step 3: Submit the completed work order to the EVTA (State agencies also require EVTA approval at this step).
Once completed, a state agency must submit this work order to the Electronic Value Transfer Administrator (Department of Taxation and Finance) for approval. The EVTAs evaluation will verify that the services to be provided are reflective of the scope of the agencys approved Program Plan. The EVTA will use the Electronic Value Transfer Administrator approved signature box on page 1 of this form to indicate its approval. The EVTA will return the approved EVTA-2 back to the agency.
An electronic copy of Form EVTA-2 can be submitted as an e-mail attachment sent to:
evta@tax.ny.gov
or a paper copy of the form can be mailed to:
EVTA Unit
NYS Department of Taxation & Finance
Room 700, Bldg. 8
State Office Campus
Albany, New York 12227
How to Complete Form EVTA-2, Work Order
An Authorized Users should complete a Form EVTA-2, Work Order for payment programs approved through the Form EVTA-1, Program Plan Application process. An Authorized User should utilize the EVTA Guidelines at HYPERLINK "http://www.tax.ny.gov/evta"www.tax.ny.gov/evta, Contractor, and OGS Contract Award Notice at HYPERLINK "http://www.ogs.ny."www.ogs.ny.gov when completing this work order. The EVTA unit is available to assist an Authorized Users in completing this work order.
This work order includes the following sections that must be fully completed, where applicable, by the Authorized User, in conjunction with the Contractor:
Section 1 Authorized User and Contractor Information,
Section 2 Work Order Check List,
Section 2.1 Initial Account Setup,
Section 3 Other Services, Training,
Section 4 Other Administrative Requirements,
Section 5 Other Services, Reporting, and
Section 6 Unique Terms or Conditions.
Section 7 Cardholder Data Storage & Service Provider (PCI DSS)
Line-by-line instructions are contained within each of these sections to assist Authorized Users in completing this work order. Most of these sections require the Authorized User to provide cost estimates for the services to be acquired from Contractor. The EVTA Rate Calculator, available for download from the EVTA Web site, is available to assist Authorized Users in developing these cost estimates. The calculator is an Excel spreadsheet comprised of separate worksheets to calculate cost estimates for the various services being acquired through the contract. These worksheets, set off as separate tabs, are located at the bottom of worksheet. The instructions within each section of this work order will direct Authorized Users to the appropriate tab within the EVTA Rate Calculator. Instructions within the calculator will guide Authorized Users in using the worksheets.
Please review the Introduction in the EVTA Rate Calculator (Intro tab) to become familiar with the set-up of the Rate Calculator and how its used to complete this work order.
Section 1. Authorized User and Contractor InformationInstructions. Please provide the following contact information for the Authorized User and American Express.
Line a. Provide the Authorized User Name and Program Name(s) as they appear on the Form EVTA-1, Program Plan Application(s). The Program # (s) is assigned by the EVTA and can be found in Part 3 of Form EVTA-1.
Line b. Provide the Authorized Users mailing address.
Line c. To be supplied by the Authorized User. Provide the name of the primary contact for this program and include their e-mail address and phone and fax numbers.
Line d. To be supplied by Contractor, provide the name of the Contractors primary contact for this program and include their
e-mail address, phone and fax numbers.
Line e. American Express account management contact for this program and their e-mail address and phone and fax numbers.aAuthorized User NameProgram Name(s)
Program #(s)
bAuthorized User Address
cAuthorized User ContactE-Mail AddressPhone Number
Fax NumberdContractor Primary ContactJohn CavanaghE-Mail AddressJohn.L.Cavanagh1@aexp.com
Phone NumberToll Free: 866-391-0005Fax NumberFax: 866-391-0005 (same as telephone)eContractor Account ContactJohn CavanaghE-Mail AddressJohn.L.Cavanagh1@aexp.com
Phone NumberToll Free: 866-391-0005Fax NumberFax: 866-391-0005 (same as telephone)
Section 2. Section 2. Contractor Work Order Check List Instructions. Please provide the following contact information.
Line a. Provide card brand and types accepting and estimated annual sales volume and average ticket value (volume/transactions).
Line b. Provide bank account information - where funds will be deposited.
Line c. Provide Non-bank card information if applicable.
Line d. Provide hardware/auto settle/middleware information if applicable. aInitial Account SetupEstimated Annual Sales Volume:$_____________________Estimated Average Ticket Value:$_____________________bBank Account Section:
Authorized User Account Information
Bank Name:_________________________________________________________________
Routing #___________________________Account #________________________________
Attach bank confirmation letter or voided pre-printed check
cNon-BankcardAmerican Express
AMEX Service Establishment Number:___________________________________________d
If using hardware method of communication: Dial-up________ or IP________
Auto Settle: yes/no:____________ If yes, specify time:___________________
If using VAR/Middleware, Provide Name:_____________________________________________________________
Section 2.1. Initial Account SetupInstructions. Complete this section for accepting American Express cards.
Line a. List the Merchant IDs as provided by Contractor, which will be used to identify the source of card payments. Use a separate column for each Merchant ID to be used. Copy the table to list more than two Merchant IDs. Enter to be provided if the Merchant IDs have not been provided before submitting this work order to the EVTA.
Line b. If multiple Merchant IDs are used, provide a brief description identifying the distinguishing characteristics of payments processed under the different IDs (e.g., NYCE transactions, district office 1 or MAC transactions, district office 2).
Line c. Identify the transfer device to be used in accepting payment cards (currently, POS terminals are the only devices satisfying the networks security requirements)
Line d. Identify the communication method for transmitting transactions between the Authorized User and Contractor.
Line e. Indicate if an Interim Working Account will be used. Authorized Users should be aware that there is a separate fee for each Interim Working Account and if using an Interim Working Account should consider using a single account for all Merchant IDs and payment sources under this contract. Report Interim Working Account cost estimates in the Account Opening and Maintenance Services line in Section 2.1 of this work order.
Line f. Identify the Authorized User account to which settled funds will be transferred. Supply a copy of a cancelled check or a letter from the Authorized User bank to Contractor authorizing transfers to the Authorized Users bank account.
Line g. Estimate the number of transactions to be processed during the balance of the first fiscal year, then, use the EVTA Rate
Calculator to estimate the processing costs for these transactions. Please refer to the instructions in the EVTA Rate Calculator C2 worksheet for the completion of costs associated with the entries made in the columns below. If there is more than one Merchant ID listed under this Section, re-use the EVTA Rate Calculator worksheet to calculate the costs for each Merchant ID. To maintain a record of these estimates before re-using the EVTA Rate Calculator, complete the program identification information at the bottom of the worksheet and print the individual sheet.
Line h. Estimate the total number of transactions to be processed during the entire term of the program and use the EVTA Rate Calculator to estimate the total processing costs for these transactions (not to exceed five years). To compute the costs for the entire term, re-use the worksheet to compute costs for each year of the program. To maintain a record of these estimates before re-using the EVTA Rate Calculator, complete the program identification information at the bottom of the worksheet and print the individual sheet.
aMerchant ID##bID UsagecTransfer Device( )POS( )POSdCommunication Method( )Dial-up ( ) Leased Line
( )ISDN ( ) Host to Host
( )Wireless(cellular)( )Dial-up ( ) Leased Line
( )ISDN ( ) Host to Host
( )Wireless(cellular)eInterim Working Account( )Yes ( )No( )Yes ( )NofAuthorized User Account
InformationBank Name :
Routing # :
Account # :Bank Name :
Routing # :
Account # :gEstimated 1st Year - # of Trans.&
Cost# of Transactions:
Cost:$# of Transactions:
Cost:$hEstimated Total-
# of Trans. & Cost
(entire term)# of Transactions:
Cost:$# of Transactions:
Cost:$
Section 3. Other Services, TrainingImplementation Training
Instructions: Describe the implementation training to be provided include dates and locations, if known. Implementation Training is provided at no additional charge.
Estimated 1st Yr. CostNo additional chargeEstimated Total CostNo additional chargeStandard On-going Training
Instructions: Describe the standard on-going training to be provided include dates and locations, if known. Standard On-going Training is provided at no additional charge.
Estimated 1st Yr. CostNo additional chargeEstimated Total CostNo additional chargeSection 4. Other Administrative RequirementsInstructions. Complete this section to identify any other administrative requirements of the Authorized User.
Line a. Identify the Authorized Unique Field and the detailed makeup of the field. Describe its use by the Authorized User and what record and positions the field is located.
Line b. Identify and describe any certification of Authorized Users interfaces to be performed by Contractor.
Line c. Identify the Authorized User person who will be receiving the monthly invoices and indicate that persons mailing address.
Line d. Identify the Authorized User person who will be receiving the chargeback data.
Line e. Identify the Authorized User person who will be receiving the records retrieval data.
Line f. Identify the records retention and/or data ownership period, not to exceed 7 years from the date of creation. If the records retention and/or data ownership requirement period is beyond 7 years, Contractor must approve this section.
Line g. Identify and describe any acceptance testing requirements beyond those provided for in the contract. If acceptance testing is beyond that contractually provided, Contractor must approve this section.
Line h. Identify and describe any other administrative requirements. Contractor must approve this section.
aAuthorized User
Unique Field 20 characters
cInvoicing: (Billing statement contact: name/phone#/address)
dChargeback(contact: name/phone#/address)
eRecord Retrievals: (contact
name/phone#/address)fRecords Retention/Data Ownership (if exceeds 7 years from creation, Contractor must approve this section)gAcceptance testing (if other than contractually provided. Contractor must approve this section)h
Other 1, specify: (Contractor must approve)Other 2, specify: (Contractor must approve)iContractor Approval SignatureContractor agrees to any and all unique terms or conditions set forth in Section 4, lines f-h above.Signature:Name:Title:Data:Section 5. Other Services, Reporting
Standard Reporting
(Contractor must approve below if this section varies from section 3.3 of the Base Agreement)
Instructions: Describe the standard reports that will be provided, include frequency (e.g., daily, monthly) and medium (e.g., paper, electronic, or both). Standard reports are provided at no additional charge.
Estimated 1st Yr. CostNo additional chargeEstimated Total Cost No additional chargeAd-Hoc Reporting
(Contractor must approve below)
Instructions: Describe the ad-hoc reports that will be provided, include frequency (e.g., daily, monthly) and medium (e.g., paper, electronic, or both). Contractor Approval Signature Contractor agrees to any and all unique terms or conditions set forth in Section 5 above.Signature:Name:Title:Data:
Section 6. Unique Terms or ConditionsInstructions. Complete this section to identify any terms or conditions required by the Authorized User beyond those provided for in the Contract. Enter None (or check no) as a response to each line in which no unique terms or conditions are required. Note: Contractor must approve this section in writing if any unique terms or conditions are identified. Unique terms and conditions can only be added through this document.
Line a. Identify and describe any security requirements beyond those provided for in the contract.
Line b. Identify and describe any confidentiality requirements beyond those provided for in the contract.
Line c. Indicate if a convenience fee will be charged to the cardholder. If you are planning on charging a fee to the cardholder, please describe how the fee will be computed.
Line d. Identify and describe any other required terms or conditions beyond those provided for in the contract.
Line e. To be completed by Contractor if any line a thru d identifies unique terms or conditions.aSecurity
bConfidentiality
cConvenience Fee
( )Yes ( )No
If yes, describe how the fee will be computed:
d
Other 1, specify: Local laws impacting payment to contractor:Other 2, specify:eContractor Approval SignatureContractor agrees to any and all unique terms or conditions set forth in Section 6, lines a - d above.Signature:Name:Title:Date:
Section 7. Unique Terms or ConditionsCardholder Data Storage Compliance & Service Provider***** PCI DSS and card association rules prohibit storage of track data under any circumstances. If you or your POS system pass, transmit, store or receive full cardholder's data, then the POS software must be PA DSS (Payment Application Data Security Standard) compliant or you (merchant) must validate PCI DSS compliance (see 1(b) below and questions 3 and 4 must be completed). If you use a payment gateway, they must be PCI DSS compliant. *****1. Have you ever experienced an Account Data Compromise "ADC"? Yes ( ) No ( ) If yes, provide date of compromise: a) Have you validated PCI DSS (Payment Card Industry Data Security Standard) compliance? Yes ( ) No ( ) If yes, go to 1(b); If no, go to #2 b) Date of compliance, Report on Compliance "ROC" or Self Assessment Questionnaire "SAQ"? c) What is the name of your Qualified Security Assessor "QSA" or Self Assessment Questionnaire (circle one "SAQ") A, B, C, or D d) Date of last scan Approved Scanning Vendor's name: 2. Are you using a "dial-up" terminal or TTC Touch Tone Capture? Yes ( ) No ( ) 3. Do you or your Service Provider(s) receive, pass, transmit or store the Full Cardholder Number "FCN", electronically? Yes ( ) No ( ) a) If yes, where is card data stored? Merchants location only Merchants Headquarters/Corp office only Primary Service Provider Both Merchant & Service Provider(s) Other Service Provider All Apply 4. What Primary Service Provider/Software Developer did you purchase your point of sale POS application from (ie software, gateway)? a) What is the name of the Service Provider/Software Developers software application?
Software Version #? b) Do your transactions process through any other Service Provider (ie web hosting companies, gateways, corporate office)? Yes ( ) No( ) c) If yes, name the other Service Provider?
Electronic Value Transfer Administrator
Form EVTA-2, American Express Work Order
Contract PS65669,
American Express Travel Related Services Company, Inc.
PAGE
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