Merchant Form
EPI 1306
PAGE 1 OF 3
EPI 1306
Merchant Application
| OFFICE USE ONLY |
Merchant # |
ISO Office Name Synapse Payments |
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SIC/MCC Code |
FICO Score |
Analyst |
ISO Office Phone 800-925-5191 |
ISO Office Phone PTS70 |
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| ISO USE ONLY |
| 1 | MERCHANT INFORMATION | |||||
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Merchant Business Name (Doing Business As) |
Merchant Legal/Corporate Name (if Different From DBA) |
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DBA Outlet Address |
Legal Address |
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DBA Outlet City, State & ZIP code |
Legal City, State & ZIP code |
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Contact Name |
DBA Location Telephone |
Customer Service Telephone # |
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Website Address (if applicable) |
Merchant Email Address (REQUIRED) |
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| 2 | IRS DISCLOSURE AND FORM W-9 NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations (see section 33.3 of your program guide for further information). |
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IRS Name : (Exactly as it appears on your Income Tax Returm) |
Federal Tax ID # (Used to file your Income Tax Return) |
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TIN Type |
MUST Check One Box |
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| 4 | OWNERS/OFFICERS/PARTNERS | |||||
|---|---|---|---|---|---|
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Owner/Principal #1 (PRINT) |
Equity Ownership % |
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Social Security # |
Telephone # |
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Residence Address |
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City, State & ZIP Code |
Date of Birth |
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Driver’s License # |
State of Issuance |
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Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy? |
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| 3 | OWNERS/OFFICERS/PARTNERS | |||||
|---|---|---|---|---|---|
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Owner/Principal #1 (PRINT) |
Equity Ownership % |
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Social Security # |
Telephone # |
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Residence Address |
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City, State & ZIP Code |
Date of Birth |
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Driver’s License # |
State of Issuance |
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Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy? |
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EPI 1306
PAGE 2 OF 3
EPI 1306
| 5 | MERCHANT PROFILE AND PROCESSING SUMMARY | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
What is your annual gross business volume?
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What is your annual credit card volume?
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What is your average charge amount?
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What is the
highest charge you will need
to process?
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WHERE IS THE
SALE
TRANSACTED?
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HOW IS THE
TRANSACTION
COMPLETED?
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When are your credit
card sales deposited?
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What is your refund
policy?
Explain if
necessary:
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What is the time frame for
delivery of the
product?
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Business
Start Date
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Are customers required to
leave deposits?
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Do you perform recurring
transactions or
auto-renewals? (Please explain)
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| 6 | MERCHANT SITE SURVEY AND SUMMARY | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Merchant location has been
physically inspected
by
agent
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Merchant lead was
generated via the
internet
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| Give a
detailed explanation
of the merchandise
and/or services sold/performed by
the merchant: |
Business Type
|
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Business Location Type
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Does the merchant inventory
and merchandise on
shelves and floor appear
consistent with the type of business specified above? (If no, please explain)
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Square
footage
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| I hereby verify that this application has been fully completed by the merchant and that the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief. Any misrepresentation may result in losses and/or liabilities. EPI may contract with a third party to schedule an external site survey and I or the merchant will schedule an appointment immediately upon request. | |||||||||||
|
James Ritter |
(REQUIRED) |
PTS70 |
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| 7 | EXISTING ENTITLEMENTS | ||||
|---|---|---|---|---|
Have you
previous
had an American Express SE #?
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| 8 |BANKING INFORMATION | |||||
|---|---|---|---|---|---|
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Transit ABA
Routing
Number
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DDA
Account Number
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| 9 | SERVICE FEE SCHEDULE | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
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| SERVICE FEE SCHEDULE: American Express OptBlue® | |||||||||
|---|---|---|---|---|---|---|---|---|---|
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| Additional Fees Include: | |||||||||
| An Inbound fee of 1% will be applied by American Express® to any Charge made by an American Express Cardmember using a Card issued by an American Express Issuer located outside of the United States. | |||||||||
| 0.30% downgrade will be charged by American Express® for transactions whenever a CNP or Card Not Present Charge occurs. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet). | |||||||||
| *0.30% to 1% processor settlement fee will be charged by Electronic Payments on any transactions processed and settled by Electronic Payments. | |||||||||
| *0.165% Network Fee will be charged by American Express® on all sales. | |||||||||
Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA
EPI 1306
PAGE 3 OF 3
EPI 1306
SERVICE FEE SCHEDULE: Rates and Percentages
NOTE:
Please refer to the program guide for additional rate descriptions. See Section 1.9 of the program guide for details regarding limited acceptance.
DISCOUNT RATE: % + $ PER AUTHORIZATION
If Discount Rate is less than 1.5%, Interchange fees will be passed through automatically unless ERR, Mid-Qual or Non-Qual options are selected. Discount Rate applies to Visa, MasterCard and Discover Network card types only. Authorization fee applies to all card types.
Additional Options
AVS Charge
Batch Charge
One-Time Setup Fee
Debit Access Fee
Other Item Fee
Wireless Transaction
Gateway Fee
MICROS Fee
Monthly Service Charge
Annual Program Fee
Monthly PCI Charge
Monthly Minimum
Merchant Advantage Program
Wireless Monthly Fee
PLEASE REFER TO THE TERMS AND CONDITIONS FOR STANDARD FEES AND THE EARLY TERMINATION FEE. EARLY TERMINATION OF THIS AGREEMENT MAY RESULT IN A MINIMUM CHARGE OF $250.00.
10 | PERSONAL GUARANTEE (NO TITLES)
Personal Guarantee: The undersigned guarantees to Electronic Payments, Inc. (“EPI”) and Wells Fargo Bank (“Bank”) the performance of this Agreement, if applicable, and any addendum thereto by Client, and in the event of default, hereby waives Notice of Default and agrees to indemnify the other parties, including but not limited to, the payment of all sums due and owing and costs associated with enforcement of the terms thereof. EPI and Bank shall not be required to first proceed against Client or enforce any other remedy before proceeding against the undersigned individual. This is a continuing guarantee and shall not be discharged or affected by the death of the undersigned and shall bind the heirs, administrators, representatives and assigns and be enforced by or for the benefit of any successor of EPI and Bank. The term of this guarantee shall be for the duration of the Merchant Processing Application and Agreement and any addendum thereto and shall guarantee all obligations which may arise or occur in connection with my activities during the term thereof through enforcement shall be sought subsequent to any termination.
Principal #1 from
Application - Signature
Date Accepted
Principal #2 from
Application - Signature
Date Accepted
Print Name
Print Name
11 | SIGNATURE
Client certifies that all information set forth in this completed Merchant Processing Application is true and correct and that Client has received a copy of the terms and conditions of any optional Electronic Payments, Inc. (“EPI”) programs Client has selected to participate in from Section 7, the Program Guide and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-11), and by this reference incorporated herein. Client further agrees that Client will not accept more than 20% of its card transactions via mail, telephone or Internet order. However, if Client’s Application is approved based upon contrary information stated in Section 5, Merchant Profile and Processing Summary section above, you are authorized to accept transactions in accordance with the percentages indicated in that section. Client authorizes EPI and Wells Fargo Bank (“Bank”) and their agents to investigate the references, statements and other data contained herein and to obtain additional information from credit bureaus and other lawful sources, including persons and companies named in this Merchant Processing Application. Client authorizes EPI and Wells Fargo Bank (“Bank”) and their agents (a) to procure information from any consumer reporting agency bearing his/her personal credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, and (b) to contact all previous employers, personal references and educational institutions. Each of the undersigned authorizes us and our Affiliates to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received from all references, including banks and consumer reporting agencies. It is our responsibility and policy to obtain certain information in order to verify your identity while processing your account application, including but not limited to, an OFAC search, MasterCard® MATCH lookup, Discover Network Consortium Merchant Negative File (“CMNF”) and inquiry into your FICO score.
By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express® Card Acceptance Agreement (“Agreement”), and that all information provided herein is true, complete, and accurate. I authorize Electronic Payments Inc. (“EPI”) and American Express Travel Related Services Company, Inc. (“AXP”) and AXP’s agents and Affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct EPI and AXP and AXP agents and Affiliates to inform me directly, or through the entity above, of reports about me that they have requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I also authorize AXP to use the reports from consumer reporting agencies for marketing and administrative purposes
I understand that upon AXP’s approval of the application, the entity will be provided with the Agreement and materials welcoming it either to AXP’s program for EPI to perform services for AXP or to AXP’s standard Card acceptance program which has different servicing terms (e.g. different speeds of pay). I understand that if the entity does not qualify for the EPI servicing program that the entity may be enrolled in AXP’s standard Card acceptance program, and the entity may terminate the Agreement. By accepting the American Express Card for the purchase of goods and/or services, or otherwise indicating its intention to be bound, the entity agrees to be bound by the Agreement.
Client agrees to all the terms of this Merchant Processing Application and Agreement. You further acknowledge and agree that you will not use your merchant account and/or the Services for illegal transactions, for example, those prohibited by the Unlawful Internet Gambling Enforcement Act, 31 U.S.C. Section 5361 et seq, as may be amended from time to time. This Merchant Processing Application and Agreement shall not take effect until Client has been approved and this Agreement has been accepted by EPI and Bank. The Agreement shall be deemed as accepted only upon the assignment and issuance of a Merchant ID Number (MID) by EPI or Bank.
Principal #1 from
Application - Signature
Date Accepted
Principal #2 from
Application - Signature
Date Accepted
Print Name
Title
PresidentPrint Name
Title
Accepted By Electronic Payments, Inc., 7800 Congress Avenue, Suite 112, Boca Raton, FL 33487
Accepted By Wells Fargo Bank, P.O. Box 6079 Concord, CA 94524
Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA
EPI 1306
PAGE A1
EPI 1306
Beneficial Ownership
Addendum
Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.
OWNERS/OFFICERS/PARTNERS
Owner/Principal #3 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #4 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #5 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
OWNERS/OFFICERS/PARTNERS
Owner/Principal #6 (PRINT)
Equity Ownership
%
Social Security #
Telephone #
Residence Address
City, State & ZIP Code
Date of Birth
Driver’s License #
State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?
7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487
7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487
Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA
EPl1306
CONFIRMATION PAGE
Please read the Program Guide in its entirety. It describes the terms under which we will provide merchant processing services to you.
From time to time you may have questions regarding the contents of your Agreement with Bank and/or Processor. The following information summarizes portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked.
Your discount rates are assessed on transactions that qualify for cer- tain reduced interchange rates imposed by MasterCard, Visa and Discover Network. Any transactions that fail to qualify for these reduced rates willbe charged an additional fee (see Section 17 of the Program Guide).
We may debit your bank account from time to time for amounts owed to us under the Agreement.
There are many reasons why a Chargeback may occur. When they occur we will debit your settlement funds or settlement account. For a more detailed discussion regarding Chargebacks, see Section 10.
If you dispute any charge or funding, you must notify us within 60 days of the date of the statement where the charge or funding appears or should have appeared.
The Agreement limits our liability to you. For a detailed description of the limitation of liability see Section 19.
We have assumed certain risks by agreeing to provide you with Card processing. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to you (see Section 22, Term; Events of Default and Section 23, Reserve Account; Security Interest).
By executing this Agreement with us you are authorizing us and our Affiliate to obtain financial and credit information regarding your business and the signer and guarantors of the Agreement until all your obligations to us and our Affiliate are satisfied.
The Agreement contains a provision that in the event you terminate the Agreement early, you may be responsible for the payment of early termination fees as set forth in Section 33, Additional Fee Information.
9. Card Organization Disclosure
Visa and MasterCard Member Bank Information: Wells Fargo Bank, N.A.
The Bank’s mailing address is P.O. Box 6079 Concord, CA 94524, and its phone number is 1 844-284-6834
Important Member Bank Responsibilities:
The Bank is the only entity approved to extend acceptance of Visa and MasterCard products directly to a Merchant.
The Bank must be a principal (signer) to the Merchant Agreement.
The Bank is responsible for educating Merchants on pertinent Visa and MasterCard rules with which Merchants must comply; but this information may be provided to you by Processor.
The Bank is responsible for and must provide settlement funds to the Merchant.
The Bank is responsible for all funds held in reserve that are derived from settlement.
Important Merchant Responsibilities:
Ensure compliance with cardholder data security and storage requirements.
Maintain fraud and chargebacks below Card Organization thresholds.
Review and understand the terms of the Merchant Agreement.
Comply with Card Organization rules.
Print Client’s Business Legal Name:_______________________________________________________________________________________________________
By its signature below, Client acknowledges that it received the complete Program Guide [Version EPll306 ] consisting of 26 pages (including this confirmation).
Client further acknowledges reading and agreeing to all terms in the Program Guide, which shall be incorporated into Client’s Agreement.
Upon receipt of a signed facsimile or original of this Confirmation Page by us, Client’s Application will be processed.
Client understands that a copy of the Program Guide is also available for downloading from the Internet at:
www.electronicpayments.com/prg/
NO ALTERATIONS OR STRIKE-OUTS TO THE PROGRAM GUIDE WILL BE ACCEPTED AND, IF MADE, ANY SUCH ALTERATIONS OR STRIKE-OUTS SHALL NOT APPLY.
Client’s Business Principal:
Signature (Please sign below):
X ________________________________________________________________
______________________________________________________
Title
___________________________
Date
________________________________________________________________
Please Print Name of Signer
___________________________________________________________________________
EPIl306 26Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA
EXATOUCH Form
AN INCOMPLETE FORM WILL CAUSE A DELAY IN PROCESSING TIME
Exatouch Setup Form
Upon completion:
New Accounts:
Email to underwriting@electronicpayments.com
Existing Accounts:
Email to exatouchorders@electronicpayments.com
|
EPI Office Code (if applicable) PTS70 |
Agent Email Address * jamesr@synapsepayments.com |
Agent Phone Number 800-925-5191 |
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Account Type |
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Merchant Name |
Pick-A-Tier Schedule * E |
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Merchant ID Number |
Merchant Email Address * |
Merchant Phone Number |
Current Terminal/POS Solution * N/A |
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File Build Type |
Restaurant and QSR Merchants Only: Online Ordering? |
Reverse Cash Discount % or $ |
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I agree to submit my menu/inventory via the online submission website For menu build instructions and to upload your menu files, visit www.electronicpayments.com/menuupload For inventory build instructions and to upload your inventory file, visit www.electronicpayments.com/inventory |
I have completed a live online demo with the Exatouch Team |
Estimated Install Date |
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Rush Orders and Requests
Exatouch orders take an average of 14 business days for deployment (pending approval of menu and inventory builds, etc.). If you require a rush, please select from the following options. These options apply to an Exatouch POS install for an existing or new MID as well as ownership changes/transfers.
Does NOT require or include a menu/inventory build.
Merchant to receive Exatouch hardware within 2 business days.
Merchants pays for Overnight Shipping.
Includes menu/inventory/build.
Merchant to receive Exatouch hardware within 5 business days.
5-day count starts on the day EPI receives the menu/inventory.
Responsibility of agent/merchant to provide complete menu/inventory using EPI templates.
Merchant pays for Expedited Shipping.
NOTE: Rush Order Fees are not refunded if a return is requested. Restocking fees apply if return requested within 30 days of shipping.
Page 2
AN INCOMPLETE FORM WILL CAUSE A DELAY IN PROCESSING TIME
Shipping Details
If shipping Express, we will confirm the total shipping costs after assessing the item(s) being sent and the type of Express shipment. We cannot guarantee overnight shipping the same day the paperwork is received.
| POS Bundle Shipping | ||
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| Peripheral Shipping | ||
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Order Notes/Instructions |
Shipping Name |
Shipping Phone Number |
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Address |
Apt/Suite# |
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City |
State |
ZIP Code |
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Total Monthly Service and Support FeeBilled Monthly on Merchant Statement |
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Misc Price Adjustments |
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|---|---|
Total Hardware and Peripheral Charges |
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Total ShippingPOS Bundle Shipping + Peripheral Shipping (per item) |
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Ownership Change/TransferFee |
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Rush Fee |
Subtotal |
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|---|---|---|---|---|
Sales Tax % |
Sales Tax % |
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TOTAL ONE-TIME PAYMENT |
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Overages for residential delivery, Saturday delivery, special handling and costs for shipping to AK and HI will be passed through. Orders shipped to Texas,New York, or picked up at the Electronic Payments New York office, will be subject to state sales tax.
| Payment Options | |||
|---|---|---|---|
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Credit Card Number |
Expiration Date |
Security Code (CVV2) |
Billing ZIP Code |
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Printed Name |
Cardholder Signature |
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*Please note that the ACH approval process may take up to five (5) business days to complete before hardware is shipped
Page 10
AN INCOMPLETE FORM WILL CAUSE A DELAY IN PROCESSING TIME
Exatouch® Terms, Conditions, and Service Agreement
Exatouch Return Policy
To be eligible for a return, all equipment must be undamaged and in the same new condition as when it was originally shipped. If you are returning within 30 days from the date of delivery and the return is approved, you will be charged a restocking fee based on 15% of the total equipment cost. NO returns will be accepted after 30 days past the date of delivery.
Exatouch Bundle Warranty
Electronic Payments shall provide remote support to determine if Exatouch Bundle hardware is defective and, if so, at Electronic Payments sole discretion, it will: repair hardware, send replacement parts, and/or replacement hardware if the merchant is actively processing with Electronic Payments. Merchant must return all defective hardware to Electronic Payments within 15 days of receipt of the replacement hardware. Merchant's failure to maintain the hardware or blatant mishandling shall result in additional charges for service and/or replacement of the hardware. Exatouch Bundle Warranty is valid for 36-month term.
Ownership Change/Transfer Policy
TFor any Exatouch ownership changes, Electronic Payments requires a 14-day advanced notice and will assess a $350 Transfer Fee to implement ownership and/or MID changes. An ownership transfer request made with less than a 14-day notice will be charged a $1,000 Rush Fee. While our team will do our best to accommodate rushed ownership changes, they're not guaranteed. An Ownership/MID change requires NO menu/inventory changes. For any Inventory/Menu Re-Builds, an additional $250 fee will be assessed. Such fees do not apply to ISO-owned equipment/stock that have not been previously deployed and in-use as an initial deployment is included in the purchase price of all POS Stations.
Changes to Terms and Fees
Electronic Payments may change any terms, conditions, rates, fees, expenses, or charges incurred under this Agreement with 30-day written notice to merchant. Using the Exatouch POS software or hardware after a change takes effect constitutes acceptance of the change.
THE SERVICE AGREEMENT REQUIRES THE USE OF ELECTRONIC PAYMENTS TRANSACTION PROCESSING SERVICES UNDER A SEPARATE MERCHANT TRANSACTION PROCESSING AGREEMENT.
By signing below, I agree to the Exatouch Return Policy and all other program terms and conditions.
|
Merchant Name (Printed) |
Merchant Signature |
Date |
Page 11
AN INCOMPLETE FORM WILL CAUSE A DELAY IN PROCESSING TIME
Exatouch® Buyer Information Sheet & Pre-Install Checklist
For Questions:
(800) 966-5520 - Option 4
Email to underwriting@electronicpayments.com
Welcome to the Electronic Payments family, and congratulations on selecting Exatouch® as your point of sale solution! Exatouch has everything you need to securely process all payment methods while maximizing business operations and increasing the value of your business. Our in-house staff is readily available to help you get the most out of your system and address any questions or concerns you may have. Our support teams may be reached at the following phone numbers:
24/7 Technical Support: 800-966-5520 – Option 3 | Merchant Support: 800-966-5520 – Option 4
As part of our comprehensive service offerings, our support staff will provide over the phone install assistance and training to ensure you can start using Exatouch as soon as possible. We’ll show you how to process a transaction, look up and pull reports, access helpful resources, and any other functions that are vital to your business operations. An initial one hour training will be completed after installation. The Technical Support Team is available to assist in the future as needed, and additional training may be scheduled at any time.
To ensure a smooth setup of your Exatouch system, please review and check off the following Pre-Installation Checklist boxes and sign below:
I,______________________________________________________________, authorized representative of_______________________________ confirm that I have read and understand this information. I authorize and request delivery of my Exatouch system to the address below and authorize anyone at that location to accept and sign for the delivery. I understand that standard turnaround is approximately 14 business days from submission of paperwork, but delays are possible due to payment issues or incomplete data.
|
Merchant Name (Printed) |
Merchant Signature |
Date |
|
Merchant Contact Name (Printed) |
Company Name |
Phone Number |
|
Address |
City |
State |
ZIP Code |
CLIENT COPY
Page 12
AN INCOMPLETE FORM WILL CAUSE A DELAY IN PROCESSING TIME
Exatouch® Buyer Information Sheet & Pre-Install Checklist
For Questions:
(800) 966-5520 - Option 4
Email to underwriting@electronicpayments.com
Welcome to the Electronic Payments family, and congratulations on selecting Exatouch® as your point of sale solution! Exatouch has everything you need to securely process all payment methods while maximizing business operations and increasing the value of your business. Our in-house staff is readily available to help you get the most out of your system and address any questions or concerns you may have. Our support teams may be reached at the following phone numbers:
24/7 Technical Support: 800-966-5520 – Option 3 | Merchant Support: 800-966-5520 – Option 4
As part of our comprehensive service offerings, our support staff will provide over the phone install assistance and training to ensure you can start using Exatouch as soon as possible. We’ll show you how to process a transaction, look up and pull reports, access helpful resources, and any other functions that are vital to your business operations. An initial one hour training will be completed after installation. The Technical Support Team is available to assist in the future as needed, and additional training may be scheduled at any time.
To ensure a smooth setup of your Exatouch system, please review and check off the following Pre-Installation Checklist boxes and sign below:
I,______________________________________________________________, authorized representative of_______________________________ confirm that I have read and understand this information. I authorize and request delivery of my Exatouch system to the address below and authorize anyone at that location to accept and sign for the delivery. I understand that standard turnaround is approximately 14 business days from submission of paperwork, but delays are possible due to payment issues or incomplete data.
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Merchant Name (Printed) |
Merchant Signature |
Date |
|
Merchant Contact Name (Printed) |
Company Name |
Phone Number |
|
Address |
City |
State |
ZIP Code |
ELECTRONIC PAYMENTS COPY
Page 12