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CHASE 0
<br />Pamentech
<br />�17
<br />Merchant Services * 4 Northeastern Boulevard, Salem, NH 03079-1952 * www.chasepaymentech.com •
<br />Phone: (603) 896-6000 * Fax: (603) 896-8715 * Merchant—Services@ChasePaymentech.com
<br />Afnfo- Whan -caffinn tin mififinip hank arcniints- please complete a senarate form for each.
<br />SECTION,9:. BANKACCOUNT INFORMATION
<br />Check only one'
<br />Settlement Currency in Which' -we
<br />Deposit I
<br />•Pomplette all sections
<br />ofthe i,options
<br />I
<br />will -fu I rid to you
<br />(Couintry4ihere yo*u'r Ba nk Acct
<br />.
<br />'
<br />listed:
<br />-
<br />ow,
<br />b6l'
<br />I
<br />Reiidii)
<br />Option #1 ED
<br />USD
<br />USA
<br />A, E
<br />(See section A Note section)
<br />Option #2 ❑
<br />CAD
<br />CAN
<br />B1 to B3, E
<br />Option #3 El
<br />USD
<br />CAN
<br />B1 to B3, D3, D4, E
<br />Option #4 [1
<br />USD
<br />Int'l
<br />C1 to C3, D1, D3, D4, E
<br />(list country funds are being deposited in
<br />Option #5 [1
<br />E]Euro, MGBP, El JPY, MAUD, El
<br />Euro Bank or SAME as
<br />C1 and/or C2, C3, E
<br />HKD, MDKK, [:1CHF, FINOK, MSEK,
<br />presentment/settlement currency
<br />[:INZD, EIZAR
<br />Option # 6 El
<br />E]Euro, MGBP, El JPY, FIAUD, El
<br />If DIFFERENT than Settlement
<br />C1 and/or C2, C3, Di
<br />HKD, MDKK, [:ICHF, E)NOK, EISEK,
<br />Currency
<br />and/or D2, D4, E
<br />ONZD, OZAR, MUSD
<br />Int'l
<br />(list country funds are being deposited in
<br />Option #7 ❑
<br />[]Euro, MGBP, [:] JPY, MAUD, M
<br />CAN
<br />131 to 83, D1, D4, E
<br />HKD, MDKK, E:1CHF, []NOK, [:ISEK,
<br />EINZID, EIZAR
<br />.
<br />Se4566-n-''A
<br />(select only one method of transfer)
<br />ED ACH Transfer
<br />I
<br />I
<br />L
<br />1- (ASA #)
<br />El Wire Transfer (See Note)
<br />(Fedwire#lRouting #)
<br />El Swift Transfer (See Note)
<br />(Swift Code: (8 to 11 bytes)
<br />Please Note: Swift code is required if your division is located outside of the US or Canada and is settling funds in USD.
<br />Wire transfer requires both A CH ABA# and FedwireViRouting#,
<br />Special Wire Instructions: (60 bytes)
<br />Bank Account #: Company Name: (As appears on Bank Account)
<br />Financial Institution Name:
<br />City: State: Zip/Postal Code:
<br />0 Checking OR El Savings
<br />Country: United States
<br />'Section El"CANADIAN.BANK ACGOUNT,.INFORMATION-':-T.ia'nsfi6rMi?thod EFT Ciinly'
<br />131 Institution Number: EFT Branch Transit Number: I I I
<br />B2 Swift Code: (8 to 11 bytes) 1 1 1 1 (required if settlement is USD)
<br />B3 Bank Account # Company Name: (As appears on Bank Account)
<br />Financial Institution Name:
<br />City: Province: Postal Code: Country: Canada
<br />❑ Checking OR n Savings
<br />8 156
<br />Rev1 1/18/10 New Division/cboo
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