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Instructions Attachment 3 Follow the instructions below to complete the Program Plan Application tab.
The Program Plan Approval tab is locked and is not to be completed by your organization.
| Part 1, A. Contact Information |
| Enter requested Contractor Name and Contractor's corresponding Contract Number. Enter Program Plan Application date. Enter your Organization Name, Division Name, Payment Program Name, and a Desription of the Program. Please note: Separate Program Plan Application Forms must be submitted to OGS for each Payment Program within your Organization or Division. |
Provide Contact Information for TWO indivduals within your organization.
| Part 1, B. Description of Existing Payment Program |
| Question 1: Enter a brief description of your existing payment program. If no program exists, enter "n/a". |
Questions 2-7: Select the applicable response from the drop-down, and provide additional information by typing in the boxes below your selection.
| Part 1, C. Description of Proposed PPS Program |
| Answer all questions about your desired payment program. |
| Part 1, D. Description of Program Attributes and Procedures |
| Type your responses in the "Description" boxes provided. |
List the payment gateway provider and point of sales terminals and/or software being used. Include Make and Model Number of all Point of Sales terminals in use.
| Part 1, E. Transaction and Collection Information |
| Select the fiscal year from the drop-down below "Actual Collections". |
Provide the actual number of transactions, dollar value, and average ticket for the fiscal year in the cells provided.
Select the next two fiscal years from the drop-down below "Projected Collections".
Provide the anticipated number of transactions, dollar value, and average ticket that you expect in the next two fiscal years for the desired payment program.
| Part 1, F. Total Projected Number of Transactions |
| Enter the information requested for the next two fiscal years based on the projected number of transactions for your desired payment program. |
| Part 2, A. Payment Processing Services Contractor Services - Projected Costs |
| Enter the information requested for the next two fiscal years based on projected costs for your desired payment program. |
Some cells are locked and will calculate automatically based on values you enter.
| Part 2, B. Payment Processing Services Benefits - Projected |
| Enter the information requested for the next two fiscal years based on projected benefits from your desired payment program. |
Some cells are locked and will calculate automatically based on values you enter.
| Part 2, C. Net Impact of Offering Payment Processing Services - Projected |
| Net Impact cells are locked and will calculate automatically based on values you enter. |
Enter a response to a or b, based on the Net Impact to your organization.
Program Plan Application
| Attachment 3 - Program Plan Application Form | | |
| Application Date: | Please enter a date | |
| Part 1, A. Contact Information | | |
| Contractor Name: | | |
| Contract Number | | |
| Program Plan Application Date: | | |
| Authorized User Name (Organization Name): | | |
| Authorized User Division Name: | | |
| Authorized User Payment Program Name: | | |
| Description of Payment Program: | | |
| Payment Program Address: | | |
| Contact Individual | Secondary Contact Individual |
| Contact Person Name: | | |
| Title: | | |
| Contact Person's Organization Name | | |
| Contact Person's Division Name: | | |
| Contact Person's Address Line 1: | | |
| Address Line 2: | | |
| City, State, ZIP: | | |
| Phone: | | |
| Email Address: | | |
| Part 1, B. Description of Existing Payment Program | | |
| 1 | Description of existing program if applicable (please respond N/A if not applicable): | |
| 2 | Description of customers served: | Individuals Businesses Other (describe below) |
| Other Description: | |
| 3 | Types of payments currently accepted: | Cash Checks Credit Debit |
ACH Other (describe below)
| Other Description: | |
| 4 | How frequently do customers remit payments? | One-Time Payments Regular Payments (recurring) Other (describe below) |
| Other Description (payment processing): | |
| 5 | How are payments received? | Along with statement Separate from any form Electronically |
Online Other (describe below)
| Other Description: | |
| 6 | Where are payments received? | Agency receives payments Received at Remote Locations (indicate below how many locations) |
Other (describe below)
| Number of Locations: | |
| Other Description: | |
| 7 | Do you currently offer a Payment Processing Services program? | Please Make a Selection |
| Description of Program and Name of Contractor: | |
| Part 1, C. Description of Proposed PPS Program | | |
| 1 | Desired Implementation Date: | Please enter a date |
| 2 | Provide a description of the desired Payment Processing Services program: | |
| 3 | How will you be offering Payment Processing Services transactions? | Face-to-Face Transactions Internet Transactions IVR Transactions |
Mail Order Transactions Telephone Order Transactions Electronically
Mobile Other (describe below)
| Other Description: | |
| 4 | What services will you use to implement PPS programs? Maybe what credit card types will you be using? | MC/Visa/Discover American Express Other (describe below) |
| Other Description: | |
| 5 | If you are developing an Internet and/or IVR application that will offer Payment Processing Services payment options through a third party gateway provider, describe your plans to procure these services. | |
| 6 | If you are offering credit/off-line debit card payments, do you plan to pass the merchant fee onto your customers? | Please Make a Selection |
| Methods to be used: | |
| 7 | If you will be offering an Internet and/or IVR application, do you plan to pass any usage fees onto your customers? | Please Make a Selection |
| Methods to be used: | |
| Part 1, D. Description of Program Attributes and Procedures |
| Customer Benefits |
Discuss the benefits that will be provided to your customers by offering PPS payment options. Examples include: convenience of offering multiple payment options, PPS facilitates e-commerce transactions over the Internet offering 24 x 7 service, eliminates the need to travel or mail payments, customers receive benefits from their credit/charge card (e.g., air miles, additional time to pay), etc.
| Description: | Please enter a response |
| Authorized User Benefits | |
Discuss the benefits that your agency will receive by offering EVT payment options. Examples include: reduced manual processing requirements, reduced errors associated with processing paper transactions, increased compliance (i.e., customers may make payments if they do not have the cash on hand), the agency may receive funds sooner (i.e., eliminates mail delays and reduces the time to deposit), guarantees funds since transactions are pre-approved and reduces or eliminates the potential for dishonored checks, allows the agency to reallocate staff, the agency benefits from a statewide contract minimizing redundant procurement efforts, etc.
| Description: | Please enter a response |
| Internet and Interactive Voice Response Applications | |
If you will be offering EVT payments over the Internet and/or through Interactive Voice Response application, provide a description of these services and the associated benefits (both financial and other) to authorized user and your customers.
| Description: | Please enter a response |
| Retaining Customer Signatures | |
Discuss the procedures your agency will use to retain customer authorizations and, if any special procedures will be developed to store and/or retrieve this information.
| Description: | Please enter a response |
| Associating E-Payments to Transactions | |
If applicable, discuss how your agency plans to associate e-payments to transactions (e.g., do you plan to store cross-reference fields such as the Authorized User Unique Field to associate e-payments to transactions). Also, discuss how your agency plans to handle rejected transactions and how it will provide receipts to your customers.
| Description: | Please enter a response |
| Methods for Reconciling E-Payments and Invoices | |
Discuss how your agency plans to reconcile electronic payments submitted with settled funds (i.e., verify that correct number of transactions were processed and correct amount of funds were received) and how you will reconcile and process vendor invoices (i.e., verify that you are charged for the correct number of transactions at the correct rate).
| Description: | Please enter a response |
| Refunds and Chargebacks | |
Discuss how your agency plans to handle refunds and chargebacks including any special procedures for accessing and retrieving information, and if you plan to have any special notices that you will provide to your customers to minimize chargebacks, etc.
| Description: | Please enter a response |
| Security | |
Discuss how your agency plans to handle security of stored and transmitted e-payment information (e.g., credit card numbers, ACH bank account information, etc.).and ensure PCI compliance.
| Description: | Please enter a response |
| Other | |
Please provide any additional information about your plans to offer EVT applications that will assist the EVTA and the Division of the Budget in reviewing your agency plans.
| Description: | Please enter a response |
| Please list the payment gateway provider being utilized to process transactions for this payment program: | Please enter a response |
| Please list the point of sales terminals (Make/Model) and/or software being utilized to process transactions for this payment program: | Please enter a response |
| Part 1, E. Transaction and Collection Information | | | | |
| | Actual Collections | Projected Collections | |
| | Please Make a Selection | Please Make a Selection | Please Make a Selection |
| 1 | Transactions: | | | |
| 2 | Value ($): | | | |
| 3 | Average Ticket: | | | |
Part 1, F. Total Projected Number of Transactions
| 1 | Projected Usage Percent - All Types of Transactions (%): |
| 2 | Projected Number of Payment Processing Services Transactions: |
| 3 | Projected Value of Payment Processing Services Transactions ($): |
| Part 2, A. Payment Processing Services Contractor Services - Projected Costs | | | |
| i. Recurring Costs | | | |
| a. | Gross Transaction Fees ($) | | |
| Less: Device User Convenience Fees ($) | | |
| Net Transaction Fees (calculated) | $ - 0 | $ - 0 |
| b. | Equipment Lease Fees ($) (please write N/A if not applicable) | | |
| c. | Equipment Rental Fees ($) (please write N/A if not applicable) | | |
| d. | Other Recurring Costs (Explain Below) | Please Make a Selection | Please Make a Selection |
| Other Recurring Costs ($) | | |
| Other Recurring Costs (Explain) | | |
| e. | Other Agency Recurring Costs (Explain Below) | Please Make a Selection | Please Make a Selection |
| Other Agency Recurring Costs ($) | | |
| Other Agency Recurring Costs (Explain) | | |
| ii. Non-Recurring Costs | | | |
| a. | Equipment Purchases ($) | | |
| Provide description of purchased equipment (Make/Model) | | |
| b. | Other Non-Recurring Costs (Explain Below) | Please Make a Selection | Please Make a Selection |
| Other Non-Recurring Costs ($) | | |
| Other Non-Recurring Costs (Explain) | | |
| c. | Agency Development Costs | Please Make a Selection | Please Make a Selection |
| Agency Development Costs ($) | | |
| Provide brief description of Agency Development Costs | | |
| iii. Total Payment Processing Services Costs (calculated) | | $ - 0 | $ - 0 |
| Part 2, B. Payment Processing Services Benefits - Projected | | | |
| i. Cost Savings | | | |
| a. | Benefit from reduced cash/check processing costs ($) | | |
| b. | Benefit from eliminating mail delays ($) | | |
| c. | Benefit from reducing dishonored checks ($) | | |
| d. | Benefit from increased collections (i.e. less uncollectables) ($) | | |
| Other Cost Savings: List other cost savings in e - g. | | |
| e. | | | |
| f. | | | |
| g. | | | |
| ii. Total Payment Processing Services Savings (calculated) | | $ - 0 | $ - 0 |
Part 2, C. Net Impact of Offering Payment Processing Services - Projected
| i. Net Impact (Total Payment Processing Services Cost - Total Payment Processing Services Cost Savings) | | $ - 0 | $ - 0 |
| a. | If the Net Impact offering Payment Processing Services results in an additional cost to your agency, indicate how your organization is proposing to cover these costs. | Please enter a response | |
| b. | If the impact is to result in a savings, indicate how your organization proposed to repurpose these saving or reallocate to a different program area. | Please enter a response | |
Program Plan Approval Program Plan Application Form Part 3, Program Plan Approval
| Introduction |
| For State Agencies: Part 3, Program Plan Approval is used to inform State agencies if their Program Plan Application has been approved or disapproved. The Office of General Services (OGS) Electronic Value Transfer Administration (EVTA), and the Division of the Budget (DOB) approval is required. |
For Non State Agencies: Office of General Services (OGS) Electronic Value Transfer Administration (EVTA) is required. (DOB approval is not required for Non State Agencies.)
For State Agencies and Non State Agencies: An approved Program Plan Application Form authorizes the implementation of an electronic payment program in accordance with the application. Separate Program Plan Application Forms must be submitted for multiple payment programs within an agency, division or organization. Disapproval prohibits the implementation of an electronic payment program as requested in the Program Plan Application Form. Applicants may, however, modify and resubmit a Program Plan Application Form for approval. In order to utilize any of the Office of General Services' (OGS) Payment Processing Services Contracts, State Agencies and Non-State Agencies will be required to provide the Contractor with a copy of this Program Plan Approval indicating their plan has been approved.
| OGS Payment Processing Services Contracts |
| A copy of Part 3, indicating the Program Plan Application is "Approved" must be provided to the Contractor in order for the Contractor to provide billable services. If Applicant is choosing to accept American Express branded cards, a copy of the approved application shall also be provided to American Express (Contract PS65669). |
| Completion of Sections B & C |
| Section B, State Agency Application Status. Will be completed by the OGS (EVTA) and DOB and is used to indicate the outcome of the evaluation process for applications submitted by State Agencies. If the "Approved" box is checked, the Program Plan Application is approved. If the "Disapproved" box is checked, the Program Plan Application is disapproved. Approval is in effect for the full term of the Payment Processing Services Contract, except that a modified Program Plan Application Form must be submitted to the OGS EVTA in order to receive approval to expand the scope of services, or if the scope of services expands beyond those identified in the attached approved program plan. Please note: A new Program Plan Application Form must be submitted for OGS (EVTA) and DOB approval by the Authorized User to the OGS EVTA for the add-on of any additional Payment Programs within the organization. |
| Section C, Non-State Agency Application Status. Will be completed by the OGS (EVTA) and is used to indicate that the Program Plan Application is approved. Approval is in effect for the full term of the Payment Processing Services Contract indefinitely, except that a modified Program Plan Application Form EVTA-1 Application must be submitted to the OGS EVTA in order to receive approval to expand the scope of services, or if the scope of services expands beyond those identified in the attached approved program plan. Please note: A new Program Plan Application Form must be submitted for OGS (EVTA) and DOB approval by the Authorized User to the OGS EVTA for the add-on of any additional Payment Programs within the organization. |
| Section A, Applicant Information |
| Authorized User Name: |
| Payment Program Name: |
| Section B, State Agency Application Status (to be completed by OGS (EVTA) and DOB) | | | | |
| Application Status | | | Program # | |
| Approved | Disapproved | EVTA/DOB | Approval Date |
| Section C, Non-State Agency Application Status (to be completed by OGS (EVTA) | | | |
| Application Status | | Program # | |
| Approved | EVTA: | Approval Date |