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14221 Dallas Parkway,Dallas,Texas 75254 •4 Northeastern Blvd,Salem,NH 03079-1952 <br /> "'13 Paymente ch", Sales Phone(603)896-8324 • Sales Fax(603)896-8701 <br /> CHASE <br /> 4• www.chasepaymentech.com <br /> •• t• 'l. z r'rP4"`. <br /> rr�� .+i�.yr , a _NO <br /> 7`� {. <br /> 7`..-,.-Fc�Y� -- _-,2- ..�rti`.`.k*..-. '�Y'..�i,'1{,=•�"{.. J-��'•�� �t��.a- `+F:y4- <br /> COMPANY LEGAL NAME: County of Indian River-Board of County Commissioners ` ^TAXPAYER ID 59-6000674 <br /> REGISTERED TRADE <br /> NAME YEAR BUSINESS STARTED+19 <br /> 25 <br /> PHYSICAL STREET ADDRESS: <br /> (NO PO BOX OR PAID MAIL BOX) IF180127th Street <br /> CITY Vero Beach STATE FL ZIP CODE 32960 <br /> PRIMARY CONTACT Bob Solari TELEPHONE# (772)226-1845 <br /> TYPE OF ENTITY <br /> ❑INDIVIDUAL/SOLE PROPRIETOR []PARTNERSHIP ❑CORPORATION ®GOVERNMENT <br /> ❑LLC• •IF LLC,TAXED AS: ❑DISREGARDED ENTITY []CORPORATION []PARTNERSHIP <br /> TYPE OF OWNERSHIP: <br /> ❑PUBLIC ❑PRIVATE ❑NON PROFIT ❑SUBSIDIARY OF PUBLIC COMPANY ®OTHER: County Government <br /> STATE OF FORMATION FL DATE OF FORMATION(MM/DD/YYYY) 1/1/1925 11 <br /> TRADING SYMBOL FISCAL YEAR END(MM/DD/YYYY) <br /> HAS MERCHAN EVER FILED BANKRUPTCY? IF YES,WHAT CHAPTER? FILING DATE: <br /> ❑YES NO EMERGENCE DATE: <br /> e e o i � � •e o 0 e e _ <br /> � e, 'e- ,, •e •s � •e a-e e' . <br /> - e ► o �,_3,.i3, .o _ •:wu;�; _'..�?' �' ��?�".•,`'m«._..•�st.:rEa:+:sPd��aS« .d�°k <br /> SOCIAL SECURITY BIRTHDATE <br /> NAME OR <br /> OR <br /> TAX ID NUMBER DATE OF INCORPORATION <br /> STREET ADDRESS TELEPHONE NUMBER <br /> CITY STATE ZIP CODE <br /> SIGNATURE PERCENT OWNERSHIP <br /> SOCIAL SECURITY BIRTHDATE <br /> NAME OR <br /> OR <br /> TAX ID NUMBER DATE OF INCORPORATION <br /> STREET ADDRESS TELEPHONE NUMBER <br /> CITY STATE ZIP CODE11 <br /> SIGNATURE1 11 PERCENT OWNERSHIP <br /> DO YOU HAVE ANY ADDITIONAL OWNERS(NOT LISTED ABOVE)THAT HAVE 10%OR GREATER OWNERSHIP,EITHER DIRECTLY OR INDIRECTLY? <br /> ❑YES OWNER ADDENDUM REQUIRED(SALES REPRESENTATIVE WILL PROVIDE) §4NO <br /> - - - - - ------------- - - - - - <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 109e.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 /> 159 <br />