HomeMy WebLinkAboutCORRESPONDENCE - PURCHASE ORDER - 9172505 (2)Invoice
Invoice 10-125654
Date 4/14/2017
Page 1/1
Invoice Due Date 4/29/2017
Please direct questions to AR@basiconline.com or call 269.488.6271
Bill To: City of Fort Collins
215 N Mason St
Fort Collins CO 80522
Plan Year / Purchase Order
No. Customer ID Payment Terms
2016 129951 Net 15
Quantity Description Unit Price Ext. Price
2,073.0 ACA Elevate Option 1 - Qualified Individual Fee (at time of
filing)
$3.500 $7,255.50
41.0 ACA Elevate Option 1 - Qualified Individual Fee - Adjusted
to Final Count
$3.500 $143.50
2,073 actual count - 2,032 estimated count = 41
2,073.0 ACA Elevate Option 1 - 1095-C Mailing Fee Per EE $4.000 $8,292.00
Subtotal $15,691.00
Please do not pay this invoice. Your fees will be
charged to the credit card on file per Tax $0.00
your instructions on or about the invoice due Freight $0.00
date. Thank You.
Total $15,691.00
Remit to:
BASIC
9246 Portage Industrial Drive
Portage MI 49024
Thank you – we really appreciate your business!
Please reference your Customer ID and Invoice number on all payments.