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CHASEMerchant Services 9 4 Northeastern Boulevard,Salem, NH 03079-1952 9 www chasepaymentech.com <br /> • <br /> Paymentech Phone (603)896-6000•Fax: (603)896-8715•Merchant-Services@ChasePaymentech.com <br /> T <br /> Account Where Your Funds are Deposited <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 /> A r,1 <br /> 'AC UN V, <br /> blk" <br /> '��N� INFORM) <br /> Intfl,'Deposits.goinar. re"aireSection <br /> d::i;"�- i <br /> .RJ4_7A'tr1' :.je7o-m- ie'te-.Se"C'tidi' <br /> -q-t rough J.,P.,,Mbr n. <br /> D1 Swift Code (8 to 11 bytes) <br /> D2 Sort Code (Required in Great Britain Only) <br /> D3 I Wire Transfer (USA Only) (Routing#) <br /> D4 Financial Institution Name <br /> City- State/Province: Postal Code/Zip- Country- <br /> Special Wire Instructions. (60 bytes) <br /> .......... <br /> -On behalf of County of Indian River Board of County 1, Bob Solari <br /> Commissioners represent and warrant <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 /> Board of County <br /> Commissioners <br /> Authorized Signature* Title Date <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 /> ---------------------------------------------------------------------------------------------------------------------- <br /> A TTA CH VOIDED CHECK HERE <br /> ------------------------------------------- -------------------------------------------------------------------------- <br /> Revl 1/18/10 9 New Division/cboo 157 <br />