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Reset form <br />MERCHANT PROCESSING APPLICATION AND AGREEMENT (Page 1 of 3) <br />Eli Bank <br />:arises lam ter;egmantarii• <br />Legal Name: Indian River County Board of County Commissiord 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: 3296 <br />Customer Service Phone: <br />Fax Phone: <br />Cell Phone: <br />E -Mail Address: <br />Website URL Address: <br />TIN Type: IE 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 />County of Indian River <br />El Federal Tax ID# (as it appears on your Income tax return) <br />596-00-0674 <br />0 I certify that I am a foreign <br />entity/nonresident ellen.(If checked, please attach IRS Form W-8.) <br />Product/Services you sell: <br />Time frame from transaction to delivery: <br />of orders delivered In: 0-7 days 100 % + 8-14 days <br />Who performs product/service fulfillment? Direct X <br />% + 15-30 days % + over 30 days <br />Vendor If Vendor, add name, address, phone. <br />= 100% <br />0 Other: (specify) <br />Do you use any third party to store, process or transmit cardholder data? 0 Yes IE 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 0 Public Corp. 0 Private Corp. ❑ 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 Thls Location All Locations <br />Cash & Credit $ 325,842,601$ 325,842,601 <br />MasterCard/Visa $ 3,000,000 $ 3,000,000 <br />Discover/Pal/Pal $ 30,000 $ 30,000 <br />American <br />Express <br />OptBlue$ 21,000 $ 21,000 <br />Voyager <br />WEX <br />Average Card Sale Amount <br />Highest Sale Amount <br />$ 160 <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 100 <br />(4) BANKING AND FUNDING INFORMATION <br />ABA: 067014822 <br />DDA: 4308981805 <br />RI Attach a copy of funding check or bank letterhead/logo signed by a bank officer with typed ABA/DDA. Must Include bank name and address. <br />Deduct Fees: 0 Daily (excluding Flat Rate) or O Monthly (lee will apply) Bank Will Fund: i Outlet 0 Head Office <br />S PAYMENTS ACCEPTED <br />E MasterCard/Visa Credit and Signature Debit <br />E Discover Credit and Signature Debit <br />(Full Service Processing) <br />E PIN Debit <br />O PlNless Debit <br />D American Express OptBlue <br />❑ Voyager Fleet <br />❑ Voyager Tax Exempt Program <br />❑ WEX Full Acquiring <br />❑ WEX (Non -Full Acquiring) <br />❑ MC Fleet <br />❑ EBT <br />❑ American Express <br />Pass Through SE <br />0 Split Dial 0 EDC <br />33 <br />May 2018 Manual MPA - CAP # 48360 <br />