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CHASE C5 PaymentxechYM <br />14221 Dallas Parkway, Dallas, Texas 75254 •4 Northeastern Blvd, Salem, NH 03079-1952 <br />Sales Phone (603) 896-8324 • Sales Fax (603) 896-8701 <br />www.chasepaymentech.com <br />Page 1 of 2 <br />Paymentech Contract No. 063576 <br />159 <br />* ,a �, • <br />COMPANY LEGAL NAME: <br />County of Indian River -Board of County Commissioners <br />TAXPAYER ID 59-6000674 <br />REGISTERED TRADE <br />NAME <br />YEAR BUSINESS STARTED 11 1925 <br />1111 <br />PHYSICAL STREET ADDRESS: 180127th Street <br />(NO PO BOX OR PAID MAIL BOX) <br />CITY Vero Beach STATE <br />FL <br />JJJJ <br />ZIP CODE 32960 <br />PRIMARY CONTACT <br />Bob Solara <br />TELEPHONE # F(772)226- <br />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 <br />FL <br />DATE OF FORMATION (MM/DD/YYYY) <br />_ 1/1/1925 <br />TRADING SYMBOL <br />FISCAL YEAR END (MM/DD/YYYY) <br />( <br />HASVER FILED BANKRUPTCY? <br />SERCH%NOJ[IF <br />YES, WHAT CHAPTER? <br />[FILING DATE: <br />[EMERGENCE DATE: <br />•t- <br />• } • �7AG5b W.a.+"'"Iw�..n�Y'w..w.+./cww..,...r.i^.4... r-.. <br />�Py} <br />SOCIAL SECURITY BIRTHDATE <br />NAME OR OR <br />TAX ID NUMBER DATE OF INCORPORATION <br />STREET ADDRESS TELEPHONE NUMBER <br />TY STATE —11 ZIP CODE �— <br />CI <br />SIGNATURE PERCENT OWNERSHIP % <br />SOCIAL SECURITY BIRTHDATE <br />NAME OR OR <br />TAX ID NUMBER DATE OF INCORPORATION <br />STREET ADDRESS TELEPHONE NUMBER <br />CITY STATE ZIP CODE I <br />�j <br />SIGNATURE 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) §gNO <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 />Page 1 of 2 <br />Paymentech Contract No. 063576 <br />159 <br />