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14221 Dallas Parkway,Dallas,Texas 75254 *4 Northeastern Blvd,Salem,NH 03079-1952 <br /> CHASECe"O Paymentech' Sales Phone(603)896-8324 • Sales Fax(603)896-8701 <br /> www.chasepaymentech.com <br /> W <br /> -We "NINEIR&I NT <br /> COMPANY LEGAL NAME. County of Indian River-Board of County Commissioners —1 59-6000674 <br /> REGISTERED TRADE <br /> NAME yEAR BUSINESS STARTED 1925 <br /> PHYSICAL 1 <br /> STREET ADDRESS: 1801 h Street <br /> (NO PO BOX OR PAID MAIL BOX) 1 <br /> CITY Vero BeachLS TATE Fl. ZIP CODE 32960 <br /> 11 <br /> PRIMARY CONTACT Cindy Corrente E# ][(:7:7:2�)226-1845 <br /> �]F <br /> TYPE OF ENTITY <br /> r-JINDIVIDUAL/SOLE PROPRIETOR ❑PARTNERSHIP [:]CORPORATION ®GOVERNMENT <br /> FILLC* *IF LLC,TAXED AS. FlDISREGARDED ENTITY nCORPORATION [—]PARTNERSHIP <br /> TYPE OF OWNERSHIP: <br /> F1 PUBLIC ❑PRIVATE F-1 NON PROFIT ❑SUBSIDIARY OF PUBLIC COMPANY ®OTHER: County Government <br /> STATE OF FORMA DATE OF FORMATION(MM/DD/YY <br /> YY)IF YY) 1/1/1925 11 <br /> TRADING SYMBOL FISCAL YEAR END(MM/DD/YYYY) <br /> [❑ <br /> HAS MERCHANT EMERGENCE DATE. <br /> SERCI ANT EVER FILED BANKRUPTCY? IF YES,WHAT CHAPTER? FILING DATE: <br /> S <br /> FffY ME �KNO <br /> ]YE <br /> _6 <br /> WINNER` <br /> W,V,ii,Q11 i Mp*m <br /> SOCIAL SECURITY BIRTHDATE <br /> NAME OR OR <br /> TAX ID NUMBER DATE OF INCORPORATION <br /> STREET ADDRESS IF TELEPHONE NUMBER I <br /> CITY STATE HCODE]F <br /> SIGNATURE <br /> PERCENT OWNERSHIP % <br /> --IF <br /> SOCIAL SECURITY BIRTHDATE <br /> NAME OR OR <br /> TAX ID NUMBER DATE OF INCORPORATION <br /> STREET ADDRESS [TELEPHONE NUMBER 11 1 <br /> CITY =1 STATE]F_ ZIP CODE11 <br /> SIGNATURE I=PERCENT OWNERSHIP % <br /> DO YOU HAVE ANY ADDITIONAL OWNERS(NOT LISTED ABOVE)THAT HAVE 10%OR GREATER OWNERSHIP,EITHER DIRECTLY OR INDIRECTLY? <br /> F1-YES-OWNER ADDENDUM-REQUIRED <br /> RED-(SALES <br /> LES-REPRESENTATIVE- - WILL-PROVIDE) <br /> VIDE) ❑-------------------------- NO----------------------------------------------- <br /> -- --- --- ---------- ----- --- -- -- -------- --- ------ --- ---- <br /> NOTE: IF AN ENTITY/PARENT COMPANY IS LISTED IN SECTION 2 ABOVE THAT HAS 10% OR GREATER OWNERSHIP OF THE APPLICANT, IDENTIFY ANY OWNERS <br /> (INDIVIDUALS AND/OR ENTITIES)OF THE ENTITY/PARENT COMPANY THAT ULTIMATELY HAVE 10%OR GREATER OWNERSHIP IN THE APPLICANT ON THE ADDITIONAL <br /> OWNER/OFFICER ADDENDUM(SALES REPRESENTATIVE WILL PROVIDE) <br /> Rev 11/15 <br /> Page 1 of 2 Paymentech Contract No.063576 <br />