■ FEES/PRODUCTS (check if applicable)
■ TERM (check if applicable)
■ PROGRAM GUIDE
ACKNOWLEDGEMENT
(1) CLIENT INFORMATION
(5) ACQUIRING FEE SCHEDULE
Merchant Number: Tie to Merchant #:
DBA Name: Buypass FIID: ___ ___ ___ ___
Legal Name: Business Entity Type:
IMPORTANT IRS INFORMATION
■ Non-Profit ■ Non-Profit/Tax Exempt as described in 26 USC Section 501(c)(3) OR a Tribal (Native American) government or Tribal government-owned. ■ Gov’t Entity If tax exempt, provide copy of IRS Determination Letter; if Tribal government, provide evidence of tribal recognition, and proof of tribal ownership if separate entity.
NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. See the portion of your Program Guide that addresses Electronic Funding Authorization, which may be Part III, Section A.3 or Part IV, Section A.3 of your Program Guide, for further information.
Name (as it appears on your income tax return) 1 ■ Federal Tax ID#: (as it appears on your income tax return)1 ■ I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8.)
SERVICE MODIFICATION FORM (Page 1 of 4)
BANASMF20_0523Edit(ia)
DBA Name:______________________________________________________ Pricing Type: ___ ___ ___ Global Fee Table #
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Loc. ____ of ______
Client Initials_________
1 If Client is a disregarded entity under IRS regulations and has provided its owner’s taxpayer filing name and Federal Tax ID above, then please attach an IRS Form W-9.
Billed Monthly Fees (If Applicable)
Monthly Service Charge (335) $________
(will also be billed inactive months for seasonal merchants) Minimum Processing Fee (953) $________
Monthly Wireless Fee (per TID) (60J) $________
ClientLine® (OnLine Reporting) (32R) $________
Vending Gateway Service Fee
Wireless (per TID) (61T) $________
Paper Statement Fee (323) $________
Premium Equip Service Program
■ Yes ■ No (per TID) (32U) $________
Online PCI Validation Access Fee (33Q) $________
Monthly PCI Support Package (49A) $________
Clover Go Monthly Fee (per MID) (32Y) $________
Main Street Insights (49I) $________
Perka (2D6) $________
Supplies: ______________________ ( ) $________
Other: _________________________ ( ) $________
Other: _________________________ ( ) $________
Other: _________________________ ( ) $________
Other: _________________________ ( ) $________
Internet
Start-Up Fees
Global Gateway Set-up Fee (31X)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Payeezy Gateway Set-up Fee (40B)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ eCommerce Payment Platform Set-up Fee (30R)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Internet Set-up Fee (30R)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Billed Monthly Fees
Global Gateway (31Z)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Payeezy Gateway (40A)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Gateway Fee (417)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Monthly Access Fee (399)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ eCommerce Payment Platform (44M)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Internet Service Fee (394)
FEE PER TID $________ x # OF TIDs ______ = TOTAL $________ Authorizations/Other Fees4
eCommerce Payment Platform, Internet, Gateway
Global Gateway, Mastercard, Visa, Discover,
American Express, Check4
(03R, 04R, 06I, 07I, L19, 0FE) $________
Payeezy Gateway (0FC) $________
Start-Up Fees (One-Time Charge)
Account Setup Fee (339) $________
Reprogramming Fee (31A) $________
Debit Network Setup Fee (31B) $________
Clover Go Set-up Fee (per MID) (62S) $________
GRPS Vending
Download Fee (per TID) (61U) $________
Vending Wireless
Activation Fee (per TID) (61S) $________
Wireless Fee (terminal download) (31E) $________
Miscellaneous Fee (31J) $________
Equip. Purchase (ACH)2 $________
Other: __________________ ( ) $________
Total Amount $_______________ _______________ w/o tax
2 You will be charged the applicable State/City/Local Sales Tax. 3 One-time fee applicable to each unit of your equipment that is (1) enabled for TransArmor Encryption, as part of the TransArmor Data Protection service or Clover Security Plus, (2) connected to a merchant point of sale network and TransArmor® Fees
Clover Security Plus - Monthly Fee
(formerly known as
“TransArmor Solution”) (3CM) $________
TransArmor Monthly Fee (30L) $________
TransArmor per Device3 (M2A) $________
TransArmor Minimum
Monthly Fee (959) $________
TransArmor Token & Encrypt
(RSA or TDES Encryption) (12E) $________
TransArmor Token & Encrypt-VF
(VeriFone Encryption) (12I) $________
TransArmor Token Only (12G) $________
TransArmor Token Registration
(Get Token) (12H) $________
(Please refer to your Program Guide for important information about certain fees.
All fees are billed by and owed to Bank of America, N.A. - this includes any fees that reference a Payment Network name in their description.) Owner/Primary Decision Maker Name: D.O.B.: Social Security #: Home Phone: % of Ownership:
Home Address: City: State: Zip: Country:
Owner Name: D.O.B.: Social Security #: Home Phone: % of Ownership:
Home Address: City: State: Zip: Country:
Owner Name: D.O.B.: Social Security #: Home Phone: % of Ownership:
Home Address: City: State: Zip: Country:
Owner Name: D.O.B.: Social Security #: Home Phone: % of Ownership:
Home Address: City: State: Zip: Country:
PLEASE PROVIDE INFORMATION ON THE PRIMARY DECISION MAKER AND ON INDIVIDUALS WHO OWN TWENTY FIVE PERCENT OR MORE OF YOUR BUSINESS (2) MODIFICATION OF AGREEMENT
(3) PROVIDE INFORMATION ON THE OWNER(S) AND PRIMARY DECISION MAKER Client (as defined in Section 6 of this Service Modification Form) acknowledges receipt of the following Merchant Services Program Guide (“Program Guide”), which replaces any program guide and the agreements contained in it or similar terms and conditions previously provided to Client:__________________________________.
Your Existing Agreement (as defined in Section 7 of this Service Modification Form) is modified to include the fees and, if applicable, the products set forth below.
The term of the Merchant Processing Agreement (as defined in Section 6 of this Service Modification Form) is extended for _____ years from ___________.
(4) ENTITLEMENTS
■ Mastercard ■ Visa ■ Discover (Including Diners Club International®, JCB, UnionPay and BCcard) Discover Direct __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ or ■ Discover Pass Through __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Complete only if Client has a Discover Direct Strategic Relationship) ■ American Express® (includes credit and prepaid cards) ■ American Express OptBlue® 1 ■ American Express Direct: __ __ __ __ __ __ __ __ __ __ Franchise Name: ________________________________________________________________ ■ IATA/ARC Code: ___ ___ ___ ___ ___ ___ ___ ___ (for MCC 4722 only) ■ EBT (SNAP) FNS # (XREF): __ __ __ __ __ __ __
■ Voyager Fleet Annual Voyager Volume: $_________________ Participation in Voyager Tax Exempt Program: ■ Yes ■ No (if yes, additional request form required) ■ WEX Full Acquiring Annual WEX Volume: $_________________ ■ WEX (Non-Full Svc) ■ Mastercard Fleet ■ Debit Network Acceptance __ __ __ __ __ __ __ __ 84089870 ■ Gift Card (A separate set-up form is required.) 6011
Visa/Mastercard/Discover Schedule Version: _____________________________ American Express OptBlue® Schedule Version: _____________________________ 1 The American Express OptBlue program, and our pricing for it set forth on page 3 of this document are available to you if you are, and as long as you remain, qualified to participate in this program as described in Section 9 of this document; fees for American Express processing, on pages 2 and 4 of this document, apply to all American Express programs. (3) either a non-Verifone device, using the TransArmor Verifone Edition encryption method, or a Verifone device. 4 Authorization Fees apply to all Authorization attempts on both Sales Drafts and Credit Drafts (return transactions).
SERVICE MODIFICATION FORM (Page 2 of 4)
DBA Name:________________________________________________ Pricing Type: __ __ __ Visa/Mastercard/Discover Schedule Version:
____________________________________________________________ Global Fee Table # __ __ __ __ __ __ __ __ __ __ __ __
Client Initials_________
American Express OptBlue Schedule Version:
___________________________________________________________ (5) ACQUIRING FEE SCHEDULE (cont’d) BANASMF20_0523Edit(ia) Loc. ____ of ______
QUALIFIED VOLUME DISCOUNT RATES
Mastercard Credit Discount Rate (440) % % % %
Visa Credit Discount Rate (444) % % % %
Discover Credit Discount Rate (984) % % % %
American Express OptBlue Discount Rate (84A) % % % %
Mastercard Non-Debit Network Discount Rate (690) % % % % Visa Non-Debit Network Discount Rate (694) % % % %
Discover Non-Debit Network Discount Rate (948) % % % %
Regulated Mastercard/Visa/Discover Non-Debit Network Sales Discount Rate1 (27D) % % % Regulated Mastercard/Visa/Discover Non-Debit Network Sales Transaction Fee1 (28C, 28D) $ $ Regulated Mastercard/Visa/Discover Non-Debit Network Sales Auth and Return Transaction Fee1(0CD, 28D) $ Discount Rate for Mastercard World/Visa Reward Sales (660, 664) % Discount Rate for Discover Premium Sales (7AA) %
Mastercard Auth & Return Transaction Fee5 (10A, 002) $ $ $ $ Visa Auth & Return Transaction Fee5 (10D, 006) $ $ $ $
American Express OptBlue Auth & Return Transaction Fee5 (10P, 014) $ $ $ $ Discover Auth & Return Transaction Fee5 (10J, 016) $ $ $ $ ADDITIONAL DISCOUNT RATES FOR MID-QUALIFIED VOLUME2 (Does not apply to Mastercard /Visa/Discover/American Express OptBlue 2 Tier) Addl Discount Rate for Mid-Qualified Mastercard/Visa Credit2 (810, 814) % Addl Discount Rate for Mid-Qualified Discover Credit2 (990) % Addl Discount Rate for Mid-Qualified American Express OptBlue2 (81C) % Addl Discount Rate for Mid-Qualified Mastercard/Visa Non-Debit Network2 (870, 874) % Addl Discount Rate for Mid-Qualified Discover Non-Debit Network2 (968) % Discount Rate for Mid-Qualified Mastercard World/Visa Reward Sales (670, 674) % Discount Rate for Mid-Qualified Discover Premium Sales (7AE) % ADDITIONAL DISCOUNT RATES FOR NON-QUALIFIED VOLUME2
Addl Discount Rate for Non-Qualified Mastercard/Visa Credit2 Auto BB = P Auto RB = N (820, 824) % % Addl Discount Rate for Non-Qualified Discover Credit2 (994) % % Addl Discount Rate for Non-Qualified American Express OptBlue2 (82A) % % Addl Discount Rate for Non-Qualified Mastercard/Visa Non-Debit Network2 (880, 864) % % Addl Discount Rate for Non-Qualified Discover Non-Debit Network2 (978) % % Discount Rate for Non-Qualified Mastercard World/Visa Reward Sales (680, 684) % Discount Rate for Non-Qualified Discover Premium Sales (7AI) %
Mastercard Settlement (or per item) Fee (001, 002) $ $ $ $ Visa Settlement (or per item) Fee (005, 006) $ $ $ $
American Express OptBlue Settlement (or per item) Fee (013, 014) $ $ $ $ Discover Settlement (or per item) Fee (015, 016) $ $ $ $ Non-Qualified Interchange and Surcharge Fees (Key 0-340, 0-341, 0-20B, 0-35J) Auto BB = A (30D) If value is 0%, Auto RB = N (Do not key FSC) If value is greater than 0%, Auto RB = M (Key FSC) Applies to Non-qualified Mastercard, Visa, Discover, American Express OptBlue Credit and/or Non-Debit Network Transactions. See the Program Guide for more details. ___________% Mastercard/Visa Interchange Plus (Key 0-273, 0-237, 0-274, 0-27L) ■ G 549,564 (key-0) Auto BB = P Auto RB = N ■ N 553,563 (key-0)
Discover Interchange Plus (Key 0-234) ■ G 527 (key-0)
■ N 528 (key-0)
American Express OptBlue IC Plus (Key 0-286) ■ 57B (key-0) 1 Applies to Non-Debit Network Transactions identified by Issuers and Payment Networks as being subject to the June 29, 2011 Final Rule on Debit Card Interchange. 2 These rates are in addition to the above applicable Qualified Volume Discount Rate(s). 3 For each Visa, Mastercard, and Discover Card transaction you will be charged the applicable interchange rate set by Visa, Mastercard, or Discover (depending on the Card type used); plus an Assessment Fee as noted on your Interchange Rate Schedule. For each American Express Card transaction you will be charged the applicable Program Pricing for American Express OptBlue, plus an American Express Assessment Fee as noted on your Program Rate Schedule. These fees are in addition to any other fees, including any fees referenced on this Acquiring Fee Schedule. 4 For Swiped / Non-Swiped, the Payment Network Fees on the following page do not apply. 5 Authorization Fees apply to all Authorization attempts on both Sales Drafts and Credit Drafts (return transactions). 6 You will be charged the applicable pass-through fees from the Debit Networks, plus any other fees indicated on the Acquiring Fee Schedule.
Discount Fees
Accept all Mastercard, Visa, Discover and American Express OptBlue Transactions (presumed, unless any selections below are checked)
Mastercard Acceptance Visa Acceptance Discover Network Acceptance Accept MC Credit transactions only Accept Visa Credit transactions only Accept Discover Network Credit transactions only Accept MC Non-Debit Network Transactions only Accept Visa Non-Debit Network Transactions only Accept Discover Network Non-Debit Network Transactions only Pricing Method: (Select One: All Discount Rates are charged based on Gross sales volume, not the number of transactions.)
Mastercard/
Visa/Discover/
American Express OptBlue Discount Rate
Mastercard/
Visa/Discover/
American
Express OptBlue 2-Tier
Mastercard/
Visa/Discover/
American
Express OptBlue 3-Tier
Mastercard/
Visa/Discover/
American Express OptBlue Interchange Plus3
SWIPED/NON-SWIPED — DISCOUNT RATES4
Mastercard/Visa/Discover/American Express OptBlue/Debit Network Swiped Discount Rate (23Z) Auto BB = P Auto RB = N ___________%
Mastercard/Visa/Discover/American Express OptBlue/Debit Network Non-Swiped Discount Rate (24D) ___________% Non-Swiped - Mastercard/Visa/Discover/American Express OptBlue/Debit Network Transaction Fee (24B) $___________ Debit Network Rates
Debit Network Transactions
(key 0-590, 0-593, 0-597, 0-587, 0.0017-18O)6 (018, 42R) $_________ (190) _________%
Discover Pass Through
Discover Auth Fee5 (10J) $_________ Discover Settlement (or per item) Fee (015, 016) $_________ (All fees are billed by and owed to Bank of America, N.A. - this includes any fees that reference a Payment Network name in their description.) Client Initials_________
DBA Name: _________________________________________________________________________________________________ Loc. _____ of ______ SERVICE MODIFICATION FORM (Page 3 of 4)
(5) ACQUIRING FEE SCHEDULE (cont’d) BANASMF20_0523Edit(ia) Discount Fees (Cont’d)
(All fees are billed by and owed to Bank of America, N.A. - this includes any fees that reference a Payment Network name in their description.) Other Fees
Payment Network Fees
For each Visa, Mastercard, Discover, and American Express OptBlue Card transaction you will be charged the applicable Payment Network fees set by Visa, Mastercard, Discover, or American Express (depending on the Card type used) as noted on your Interchange Rate Schedule or American Express OptBlue Program Rate Schedule.
These fees are in addition to any other fees, including any fees referenced on this Acquiring Fee Schedule.
Use GFT No. / Name: Use with Fee Schedule(s):
Bundled Visa & Mastercard Access Fee of $0.0269 with Dispute Pass-Through Fees DDA 1 880000004127 / PT FEES BA W PTD DDA1 Bundled Visa & Mastercard Access Fee of $0.0269 without Dispute Pass-Through Fees DDA 1 880000004128 / PT FEES BA NO PTD DDA1 Unbundled Visa & Mastercard Pass-Through Access Fees with Dispute Pass-Through Fees DDA 1 880000004129 / PT FEES UA W PTD DDA1 Unbundled Visa & Mastercard Pass-Through Access Fees without Dispute Pass-Through Fees DDA 1 880000004130 / PT FEES UA NO PTD DDA1 Bundled Visa & Mastercard Access Fee of $0.0269 with Dispute Pass-Through Fees DDA 2 880000004131 / PT FEES BA W PTD DDA2 Bundled Visa & Mastercard Access Fee of $0.0269 without Dispute Pass-Through Fees DDA 2 880000004132 / PT FEES BA NO PTD DDA2 Unbundled Visa & Mastercard Pass-Through Access Fees with Dispute Pass-Through Fees DDA 2 880000004133 / PT FEES UA W PTD DDA2 Unbundled Visa & Mastercard Pass-Through Access Fees without Dispute Pass-Through Fees DDA 2 880000004134 / PT FEES UA NO PTD DDA2 VS / MC / DS: IG3, IN3, 3TB, 2TB, or 3RB
VS / MC: IG4, IN4
AXOB: IAX, 3TA, 2TA, 3RA
VS / MC / DS: IG1, IN1, 3TU, 2TU, or 3RU
VS / MC: IG2, IN2
AXOB: IAX, 3TA, 2TA, 3RA
Supplemental Global Fee Table for Payment Network Pass-through Fees (Internal Use Only) Check Only One:
VS / MC / DS: IG3, IN3, 3TB, 2TB, or 3RB
VS / MC: IG4, IN4
AXOB: IAX, 3TA, 2TA, 3RA
VS / MC / DS: IG1, IN1, 3TU, 2TU, or 3RU
VS / MC: IG2, IN2
AXOB: IAX, 3TA, 2TA, 3RA
Processing Fees
Chargeback Fee (ZZ9) $_________
Mastercard/Visa/Discover/American
Express Voice Auth (10B, 10E, 10K, 10Q,
039, 03A, 049, 04A, 069, 06A, 079, 07A) $_________
Mastercard/Visa/Discover/American
Express ECR/Autobats AVS
(03B, 03C, 04B, 04C, 06B, 06C, 405,
406, 407, 408, 435, 07B, 07C) $_________
American Express Direct Auth Fee (10P) $_________
ACH Reject Fee (401) $_________
Batch Settlement Fee (227) $_________
EBT (18E, 18I, 02X, 18H) $_________
Mastercard Global ePricing Service (897) _________%
Visa Global ePricing Service (898) _________%
Monthly Funding Advantage1 (158) _________%
American Express Sales Discount1 (164) _________%
Discover Sales Discount1 (170) _________%
Other: ______________________ ( ) $_________
Buypass Fees
Datawire Micronode ■ Yes ■ No
Datawire Micronode Monthly Fee (354) $_________ (each) Authorization Fees Voyager (10W) $_________
WEX (Non-Full Svc) (0D4) $_________
Other Payment Fees
Voyager:
Sales Disc’t Rate (766) _________%
Credit Disc’t Rate (767) _________%
WEX Full Acquiring Fees
WEX Auth Fee (0D4) $_________
WEX Sales Discount (840) _________%
WEX Refund Discount (841) _________%
WEX Chargeback Discount (842) _________%
WEX Chargeback Reversal Disc’t (843) _________%
WEX Retrieval Fee (29I) $_________
1 Applicable only to monthly billing and will be assessed on monthly Gross sales volume, not the number of transactions.
Early Termination Fee/Liquidated Damages
See the portion of the Program Guide that addresses early termination fees and/or liquidated damages for information on early termination fees and/or liquidated damages you may be charged. Please note that if you are a Group Owner and a Group Owner Agreement is in effect at the time of termination, the terms of the Group Owner Agreement may supersede any early termination fees and/or liquidated damages set forth in the Program Guide.
Fleet Fees
Fleet One Auth Fee (0B2) $_________
FleetCor® Auth Fee (0B3) $_________
Additional Fees (If Applicable)
Other: __________________________________________________________________ ( ) $_________ Other: __________________________________________________________________ ( ) $_________ Other: __________________________________________________________________ ( ) _________% Other: __________________________________________________________________ ( ) _________% Payment Network Fees & Fines
Failure to comply with any of the Payment Network rules may result in fees, fines or penalties.
You are responsible for any fines or penalties imposed by any payment network and any other expense and liabilities.
The Payment Networks or Bank of America, N.A. may impose fees, fines or penalties, or restrict you from accepting cards if it is determined that you are not compliant with the rules and regulations set forth by the Payment Networks. (7) AGREEMENT APPROVAL
By executing this Service Modification Form (“SMF”), Client hereby agrees to amend (1) its existing agreement for merchant services with Bank of America, N.A. (“Bank”) (“Existing Agreement”), and (2) if applicable, its existing agreement with TeleCheck Services, Inc. (“TeleCheck”) for services that TeleCheck provides (“Current TeleCheck Agreement”), all as set forth herein. Except as modified by this SMF, the Existing Agreement and the Current TeleCheck Agreement remain in full.
As used herein: (1) “Merchant Processing Agreement” means the Existing Agreement, as modified by this SMF (including the replacement agreement terms and conditions, if the Program Guide Acknowledgement box is checked in Section 2 of this SMF); (2) “TeleCheck Agreement” means the Current TeleCheck Agreement, as modified by this SMF (including replacement agreement terms and conditions, if the Program Guide Acknowledgement box is checked in Section 2 of this SMF); and (3) “Client”, “you”, and “your” mean the client identified in Section 1 of this SMF.
Any capitalized term used in Sections 1-4 or Section 6 of this SMF, but not defined in this SMF, has the meaning for such term set forth in the Merchant Processing Agreement. Any capitalized term used in Section 5 of this SMF, but not defined in this SMF, has the meaning for such term set forth in the TeleCheck Agreement.
By signing below, the undersigned, for himself or herself and for and on behalf of the Client, represents and warrants that: (1) the undersigned has received and read (a) this Service Modification Form, including if applicable the replacement agreements in the Program Guide, (b) the Non-Qualified Rate Schedule (specific to Client's industry), Interchange Rate Schedule (and American Express OptBlue Program Rate Schedule, if applicable), or Qualification Tier Rate Schedule, as applicable to Client's pricing method, and (c) the Debit Network Fee Schedules (the rate schedules referenced in (b) and (c) may be referred to as the “Rate Schedules”); (2) the undersigned is authorized to sign, submit, and agree to this SMF on behalf of Client; (3) the undersigned is authorized to disclose the owner and other information provided in this SMF, and is a primary decision maker for Client; (4) all information provided in this SMF, including the owner and primary decision maker information, is true, complete, and accurate.
No alterations or strikeouts to this SMF will be accepted and, if made, any such alterations or strikeouts shall not apply.
This Service Modification Form has been agreed to and executed by Bank (and TeleCheck, if and as applicable), without signature, and has been agreed to and executed by Client as of the date shown below. Client's signature on this Service Modification Form shall constitute Client's signature of and agreement to, as applicable, the Merchant Processing Agreement and the TeleCheck Agreement.
Client’s Business Principal:
Signature (Please sign below):
X______________________________ _______________________________ ___________________ Title Date
Print Name of Signer: __________________________________________________________________ DBA Name: _________________________________________________________________________________________________ Loc. _____ of ______ SERVICE MODIFICATION FORM (Page 4 of 4)
TELECHECK REPORT INFORMATION
Funding Report: ■ Bill To ■ Location Delivery Method: ■ E-Mail ■ Fax ■ US Mail Contact Name: ___________________________________________________________ Contact Telephone #:______________________________________________________ Report Fax #: ____________________________________________________________ Report E-Mail Address: ____________________________________________________ Batch Closing Options: _________ ■ am ■ pm Format: ■ CSV (E-Mail only) ■ PDF
TELECHECK BANKING INFORMATION
Funding: ■ Per Bill To ■ Per Location
ABA Transit #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Account #: _____________________________________ ■ Same as above or ■ Same as above or
ABA Transit #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Account #: _____________________________________ Special Instructions which are part of this Agreement: ________________________________________________________________________________________________________________ Please note on separate funding check or bank letterhead the designated TeleCheck Service. A separate funding check or bank letterhead/logo for TeleCheck Services is NOT required UNLESS Merchant will be using different banking account(s) for TeleCheck Services.
ACH Credits to TeleCheck
by Client (For Invoice Payment):
Debits/Credits (Settlement) to Client
by TeleCheck and/or Franking Information:
■ TeleCheck Auto Settle Time: _________ hh ET (Must be at least 1 hour after Card Auto Settle Time) Existing Subscriber No.: ___ ___ ___ ___ ___ ___ ___ ___
TELECHECK BILL TO INFORMATION
Your Head Office/Bill To Name: First/Last Contact Name: Phone Number:
Address: Suite # City: State: Zip: Your Fax Phone:
(6) TELECHECK RATES, SERVICE FEES, AND SET UP INFORMATION TeleCheck Services, Inc.
P.O. Box 4514
Houston, TX 77210-4514 1-800-366-1054 # of Physical TeleCheck Locations: __________ BANASMF20_0523Edit(ia)
See TeleCheck Agreement for definitions, warranty requirements and any additional fees.
TELECHECK PRODUCTS, RATES, AND FEES
Clover Check Acceptance Product Features Average Ck Size Monthly Ck Volume Monthly Minimum Inquiry Rate
Transaction
Fee Max Warranty Processing Fee
December
Risk
Surcharge
In-Person Warranty
Clover Device Corp Ck $ $ % $ $
In-Person Warranty
Non-Clover Device Corp Ck $ $ $ % $ $ $ %
In-Person Verification
Non-Clover Device Corp Ck $ $ $ % $ $ $
By Mail/Drop Box Warranty
Clover Device Corp Ck $ $ % $ $
or Face $
By Mail/Drop Box Verification
Clover Device Corp Ck $ $ $ $
By Mail/Drop Box Warranty
Non-Clover Device $ $ $ % $ $ $ %
By Mail/Drop Box Verification
Non-Clover Device $ $ $ % $ $ $
In-Person Paper Warranty (Paper)
Non-Clover Device $ $ $ % $ $ $ %
In-Person Paper Verification (Paper)
Non-Clover Device $ $ $ % $ $ $
Online Warranty Corp Ck
Recurring $ $ $ % $ $ $ %
EXECUTED WITHOUT SIGNATURE:
BANK OF AMERICA, N.A.
TELECHECK SERVICES, INC. (if applicable)
0.10 0.10
0.10 0.10
1.50 15.00
15.00 20.00
35.00 15.00
15.00 45.00
0.20 5.00
5.00 5.00
5.00 5.00
5.00 2,500 5.00
5.00 5.00
1.50 0.20
0.20