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I Resetform <br />MERCHANT PROCESSING APPLICATION AND AGREEMENT (Page I of 3) <br />© Bank <br />Mnnkft Most Con vnnM lank• <br />TD2008 is <br />(1) TELL US ABOUT YOUR BUSINESS <br />Legal Name: Indian River County Board of County Commissions Store #: <br />Loc. 1 of <br />DBA/Outlet Name: Indian River County <br />First/Last Contact Name: Raeanne Cone <br />Address: 1801 27th Street <br />Business Phone: (772) 226-1219 <br />Suite #: <br />city: Vero Beach State: FL zip: 3291 <br />Customer Service Phone: <br />Fax Phone: <br />Cell Phone: <br />E -Mall Address: <br />Website URL Address: <br />TIN Type: Ii7 EIN (Fed Tax ID #) 0 SSN <br />Retrieval Requests: 0 Dedicated 24 hour fax 0 No fax; mail O Dispute Manager <br />NOTE: Failure to provide accurate information may require us to withhold income tax from your funding per IRS regulations. <br />Name (as it appears on your income tax return) <br />Count of Indian River <br />Y <br />IN Federal Tax ID# (as It appears on your Income tax return) <br />596-00-0674 <br />0 1 certify that 1 am a foreign <br />entity/nonresident alien. <br />(If checked, please attach IRS Form W-8.) <br />Product/Services you sell: <br />Time frame from transaction to delivery: % of orders delivered in: 0-7 days 1 OO % + 8-14 days % + 15-30 days <br />Who performs product/service fulfillment? Direct X <br />+ over 30 days % = 100% <br />Vendor If Vendor, add name, address, phone. 0 Other: (specify) <br />Do you use any third party to store, process or transmit cardholder data? 0 Yes M No <br />If yes, give name/address: <br />Please identify any Software used for storing, transmitting, or processing card transactions or authorization requests. <br />(2) OWNERSHIP <br />State Organized: F L Mo/Yr Started: 06/25 0 Sole Ownership 0 Partnership 0 Non Profit/Tax Exempt ❑ Public Corp. 0 Private Corp. 0 LLC O Gov't. <br />Owner/Partner/Officer Name: <br />D.O.B.: <br />Social Security #: <br />Home Phone: <br />Ownership %: <br />Home Address: <br />City: <br />State: Zip: Country: US <br />Form of ID Verified: <br />OK 0 Expiration Date: State: <br />Owner/Partner/Officer Name: <br />D.O.B.: <br />Social Security #: <br />Home Phone: <br />Ownership %: <br />Home Address: <br />City: <br />State: Zip: <br />Country: US <br />Form of ID Verified: <br />OK 0 <br />Expiration Date: <br />State: <br />(3) BUSINESS FINANCIAL DATA <br />Total Annual Volume This Location <br />Cash & Credit $ 325,842,601 <br />MasterCard/Visa <br />$ 3,000,000 <br />All Locations <br />$ 325,842,601 <br />$ 3,000,000 <br />Discover/PayPa1 $ 30,000 $ 30,000 <br />American OptBlue Express $ 21,000 $ 21,000 <br />P <br />Voyager <br />WEX <br />Average Card Sale Amount $ 160 <br />Highest Sale Amount <br />$ 500 <br />Card Present <br />Internet <br />Mail Order/ <br />Direct Marketing <br />Phone Order <br />Total <br />100 % <br />Swiped <br />Keyed <br />Total <br />100 % <br />(4) BANKING AND FUNDING INFORMATION <br />ABA: 067014822 DDA: 4308981805 <br />8 Attach a copy of funding check or bank letterhead/logo signed by a bank officer with typed ABA/DDA. Bust include bank name and address. <br />Deduct Fees: 0 Daily (excluding Flat Rate) or O Monthly (fee will apply) Bank Will Fund: E Outlet 0 Head Office <br />(5) PAYMENTS ACCEPTED <br />I3 MasterCard/Visa Credit and Signature Debit <br />B Discover Credit and Signature Debit <br />(Full Service Processing) <br />O PIN Debit <br />O PINIess Debit <br />O American Express OptBlue <br />0 Voyager Fleet <br />0 Voyager Tax Exempt Program <br />❑ WEX Full Acquiring <br />❑ WEX (Non -Full Acquiring) <br />❑ MC Fleet <br />❑ EBT <br />0 American Express <br />Pass Through SE <br />0 Split DIaI ❑ EDC <br />May 2018 Manual MPA - CAP # 48360 <br />