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CHASE ., <br /> 'a Merchant Services•4 Northeastern Boulevard,Salem,NH 03079-1952 •www.chasepaymentech.com• <br /> Paymentech Phone (603)896-6000•Fax:(603)896-8715•Merchant_Services@ChasePaymentech.com <br /> Section C: FINAL DESTINATION BANK <br /> Account Where Your Funds are De osited <br /> C1 Swift Code. (8 to 11 bytes) <br /> C2 Sort Code (Required in Great Britain Only) <br /> C3 IBAN/Bank Account# <br /> Company Name. (As appears on Bank account) <br /> Financial Institution Name. <br /> City- State/Province Postal Code Country- <br /> Special Wire Instructions. (60 bytes) <br /> �Section.D: INTERMEDIARY/CLEARING BANK ACCOUNT INFORMATION <br /> Note:-For Intl Deposits going through J.P.Morgan Chase in London, termediary is not re uired. Complete Section"C"only <br /> D1 Swift Code. (8 to 11 bytes) <br /> D2 Sort Code (Required in Great Britain Only) <br /> D3 Wire Transfer (USA Only) I (Routing#) <br /> D4 Financial Institution Name <br /> City, State/Province Postal Code/Zip Country- <br /> Special Wire Instructions. (60 bytes) <br /> Section E: Signature <br /> "On behalf of County of Indian River Board of County I, Bob Solari represent and warrant <br /> Commissioners <br /> (Merchant Legal Name) (Print Name) <br /> that I have the authority to add banking information and I verify that the above banking information is accurate and should be used to <br /> transfer funds accordingly" <br /> qlf Q=/ .� Board of County <br /> Commissioners <br /> Authorized Signature* Title 15ate <br /> (*Must be signed by Executive or Financial Contact) <br /> Note: In order to process this request, please attach an original voided check (starter check or bank <br /> statements not applicable) or a bank letter of verification. <br /> ATTACH VOIDED CHECK HERE <br /> -------------- ----------------APPRIWEDA-S- OFORIVI <br /> Attest:Jeffrey R. Smith, Clerk of AND LEGAL SUFFICIEN <br /> Circuit Court and Comptroller •p..Ay�•• � I <br /> �•4 JNSY COittM�ss/os Y DYLAN RrINGOLD <br /> er *; •.y�; OOUNt`I''ATTORNEY <br /> s <br /> Deputy erlF •v': <br /> y`2F QN. <br /> Rev11l18/10 1NTf. �' New Division/cboo <br /> •.•O.•� <br />