HomeMy WebLinkAboutRESOLUTION NO. 2022-66RESOLUTION NO. 2022-66
RESOLUTION AUTHORIZING THE CITY OF FAIRFAX TO ENTER
INTO A MERCHANT CREDIT/DEBIT CARD AGREEMENT
WHEREAS, the Fairfax City Council needs to provide a method to receive credit and
debit card payments from residents and customers; and
WHEREAS, i3 — BIS, LLC, 333 Industrial Park Road, Piney Flats, Tennessee 37686, has
taken over ownership of the City's current credit and debit card processor and has supplied a
Merchant Credit/Debit Card Agreement.
NOW, THEREFORE, BE IT RESOLVED, by the City Council of the City of Fairfax,
Iowa, to enter into this Merchant Credit/Debit Card Agreement with i3 — BIS, LLC, 333 Industrial
Park Road, Piney Flats, Tennessee 37686.
BE IT FURTHER RESOLVED, by the City Council of the City of Fairfax, Iowa, that
the Mayor and City Clerk are hereby authorized and directed to execute both this Resolution and
the Merchant Credit/Debit Card Agreement.
Passed and approved this 12th day of July, 2022.
AYES: Nurre, Daly, Pacha, Volk, and Wainwright
NAYS: None
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Burnell G. Frieden, Mayor
ATTEST:
Cy thia Stimson, City Clerk/Treasurer
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Page 1 of 9
Merchant Credit/Debit Card Agreement
This agreement is made on this ��� day of��, 2022 between i3 - BIS, LLC (COMPANY) 333
Industrial Park Road, Piney Flats, Tennessee 37686, and the City of Fairfax, lowa (CLIENT).
❑ WHEREAS, the CLIENT desires to obtain the services of the COMPANY; and
❑ WHEREAS, the COMPANY has expertise which may be valuable to CLIENT and desires to
use such expertise to Install and maintain a Credit/Debit Card for payments collected for the
CLIENT via the web; and
❑ NOW THEREFORE, in consideration of the mutual covenants and conditions set forth herein
and other good and valuable consideration, receipt of which is hereby acknowledged, it is
agreed as follows;
SCOPE OF WORK
The COMPANY shall be authorized as the exclusive Merchant for the process of credit cards, debit
cards by CLIENT for online tax payments. The COMPANY will provide CLIENT's customers web
access to pay by credit card, debit card, via the web. The COMPANY will develop and maintain the
system and train the CLIENT personnel employed to use the web payment reporting tools. CLIENT
understands that the COMPANY will charge a percentage for each transaction and will not be
required to remit any funds to CLIENT for this service. (See Statement of Work (SOV1� in "Attachment
A" for a detailed account of Services provided in this agreement).
Payment Terms:
COMPANY will charge the following:
2.75% or $1.50, whichever is greater, for credit & debit card transactions.
All transactions processed by the COMPANY will be collected directly from CLIENT's
customers via the web site. Convenience fee may be subject to adjustments with prior
notice. CLIENT is responsible for any charge-backs.
Performance. COMPANY will perform the services necessary to complete the Project in
accordance with the procedures described in the SOW, in a timely and professional manner,
consistent with industry standards, at a location, place and time that COMPANY deems
appropriate, and all in accordance with the SOW and this Agreement. The manner and means
that COMPANY chooses to complete the Project are in COMPANY's sole discretion and control.
Statement of Work (SOW). if CLIENT and COMPANY have agreed to a written statement of
work, written project plan, or other written communication to specify in more detail the Project
scope, required features or functionality, deliverables, milestones, development methods,
resources, communications, training, acceptance, change control, payment, or other terms, such
writing ("SOW") is incorporated in and made a part of this Agreement. The SOW is appended to
this Agreement as "Attachment A".
Refund Polices. See "Attachment B" for BIS Refund Policies regarding commerce interchange.
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
v.2.1.21
Page 2 of 9
1. INDEMNITY
i3-BIS, LLC will indemnify and hold the CLIENT harmless from any and all claims, actions, liabilities,
and expenses caused by resulting from or alleging negligent or intentional acts to the extent allowed
by law.
2. PROPRIETARY RIGHTS
The COMPANY acknowledges that it shall not receive any proprietary rights in the documents of
CLIENT. These documents shall remain sole and exclusive property of the CLIENT. CLIENT does
agree that it will not enter into another arrangement or contract with any other entity for the
processing of credit card, debit card and e-check in-house or via the Internet or the Worldwide Web.
3. TERM AND TERMINATION
This agreement shall commence on July 1 st, 2022, and shall continue in full force and effect for a
period of one (1) year. Thereafter, this agreement will auto renew for periods of (1) one year until
terminated by either party by a 90 day written notice.
4. INTEL�ECTUAL PROPERTY RIGHTS
CLIENT shall have no right to sell/rent out/lend or in any way transfer or assign the right,to use the
Program or any right or obligation under this Agreement to any third party. CLIENT shall not reverse
engineer, disassemble or decompile the Program without permission from COMPANY. Should
COMPANY cease to exist or enter into bankruptcy the System and programs owned by COMPANY
will be made available to CLIENT. All Systems and programs not belonging to COMPANY shall fall
under the support or upgrade policies offered by the owner of such packages. (Example: Windows).
5. ASSIGNMENT
This agreement shall be binding upon the parties respective successors and permitted assigns.
Neither party may assign the agreement or end its rights or obligations herein.
6. NOTICES
Any notices or communication under this agreement shall be in writing and shall be hand delivered or
sent by registered mail, return receipt requested to the party receiving such communication at the
address for either party on the front of this agreement, or such other address as either party may in
the future specify to the other party.
7. GOVERNING LAW
This agreement shall be governed and construed under the laws of the State of lowa.
8. MODIFICATIONS
No modifications, amendment, supplement to or waiver of this agreement or any schedule hereunder,
or any of their provisions shall be binding upon the parties hereto unless made in writing and duly
signed by both parties.
i3 - BIS, LLC
333 industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
v.2.i.21
Page 3 of 9
9. WAIVER
A waiver of either party to exercise any right provided for hearing shall not be deemed to be a waiver
of any right hereunder.
10. SEVERABILITY
If any provision of this Agreement is, for any reason, held to be invalid or unenforceable, the other
provisions of this Agreement will be unimpaired and the invalid or unenforceable provision will be
deemed modified so that it is valid and enforceable to the maximum extent permitted by law.
11. COMPLETE AGREEMENT
This agreement represents the entire understanding of the parties as to the subject matter therein
and may not be modified except in writing executed by both parties.
12. VENDOR RELATIONSHIP
COMPANY's relationship with CLIENT will be that of a Vendor, and nothing in this Agreement should
be construed to create a partnership, joint venture, or employer-employee relationship. COMPANY
(a) is not the agent of CLIENT; (b) is not authorized to make any representation, contract, or
commitment on behalf of CLIENT.
13. CONFIDENTIAL INFORMATION
COMPANY agrees that during the term of this Agreement and thereafter, except as expressly
authorized in writing by CLIENT, it (a) will not use or permit the use of Confidential Information
(defined below) in any manner or for any purpose not expressly set forth in this Agreement; (b) will
not disclose, lecture upon, publish, or permit others to disclose, lecture upon, or publish any such
Confidential Information to any third party without first obtaining CLIENT's express written consent on
a case-by-case basis; (c) will limit access to Confidential Information to COMPANY's personnel who
need to know such information in connection with their work for CLIENT; and (d) will not remove any
tangible embodiment of any Confidential Information from COMPANY's premises without CLIENT's
prior written consent; and (e) will, with reasonable care and skill using standard business practices,
secure any confidential information received from CLIENT or it's customers while performing the
services stated within this agreement. "Confidential Information" includes, but is not limited to, all
information related to CLIENT's business and its actual or anticipated research and development,
including without limitation (i) trade secrets, inventions, ideas, processes, computer source and object
code, formulae, data, programs, other works of authorship, know-how, improvements, discoveries,
developments, designs, and techniques; (ii) information regarding products or plans for research and
development, marketing and business plans, budgets, financial statements, contracts, prices,
suppliers, and customers; (iii) information regarding the skills and compensation ot Client's
employees, contractors, and any other service providers; (iv) the existence of any business
discussions, negotiations, or agreements between CLIENT and any third party; and (v) all such
information related to any third party that is disclosed to CLIENT or to COMPANY during the course
of CLIENT's business ("Third Party Information"). Notwithstanding the foregoing, it is understood
that COMPANY is free to use information that is generally known in the trade or industry, information
that is not gained as a result of a breach of this Agreement, and COMPANY's own skill, knowledge,
know-how, and experience.
i3 - BIS, LLC
333 industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
v.2.1.21
Page 4 of 9
IN WITNESS WHEREOF, the parties hereto, each act under due and proper authority, have executed
this agreement as of the date first written herein and above.
The COMPANY (i3-BIS, LLC) CLIENT
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Name: Name: �e.� v� v�� / l �/"��, "'� ��_„�
Print Print
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
v.2.1.21
Page 5 of 9
ATTACHMENT A
STATEMENT OF WORK ("SOW")
THIS STATEMENT OF WORK (this "SOW") is entered into by and between the undersigned CLIENT and
COMPANY pursuant to the Agreement (the "AgreemenY') governing the following Project:
Customer: � City of Fairfax IA
ect Nam�Credit Card Proc
All capitalized terms not defined in this SOW have the meanings given to such terms in the Agreement, unless the
context requires otherwise. The information in this SOW shall be considered Confidential Information under the
terms of the Agreement.
1 Project Description
This Project is the Online Payment System for credit card and debit card payments.
2 Scope of Services
• Process all credit card/debit card transactions as merchant
• On-line payments will be posted real-time by BIS as agreed upon
• Provide CLIENT with transaction reporting tools
• Setup, host, and support your payment website; BIS reserves the right to make final decision
on web site setup, additions, changes, etc., requested.
• CLIENT's members will be able to pay payments via website.
3 Deliverables
The Project will be delivered as a complete service for processing credit cards through a secure web site portal
accessible from the CLIENT's web site. The CLIENT will have the ability to log onto the online service for retrieving
transactions files and for reporting of transactions for reconciliation of transactions.
4 Duration of Services
This Project wiil be started at the date of contract signing. The "Go Live" date for online credit card acceptance will
commence when CLIENT's web site portion of Webfeepay.com is complete and signed off by CLIENT and wiil
continue until termination of contract.
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
V.2.1.21
Page 6 of 9
ATTACHMENT B
Commerce Interchange Refund Policies
Refunds
BIS will only refund or be responsible for transactions that are caused through system error. Fraudulent
payments, disputed payments, overpayments, multiple payments, and other user errors will be the
responsibility of CLIENT for settling refunds or credits. BIS' sole responsibility is as the payment
processor and does not offer fund guarantees or collection services. BIS will assist CLIENT in any
payment disputes that may arise through this service.
Any and all requests for transaction Refunds must be submitted via support request to BIS. Requests
made via email will not be processed.
CLIENT must designate at least two (2) staff employees who are authorized to request a Refund. For
security reasons, only authorized designees requests will be processed. All requests must be verified by
sending an email through an authorized email account.
Refunding Procedure:
A refund request by an authorized person must be submitted with:
• Date of transaction (not date of payment).
• Name of end user.
• The transaction number and/or the last four (4) digits of the Credit Card. For security purposes
please only include the last 4 digits of the Credit Card.
• The account number should be submitted. The customer who is doing the transaction may not
be the same as the person paying for the transaction.
• A valid reason for a return.
Please list the authorized employees:
Name: (�U1��7�1i�- ST�IMS�i't Email:��-hlnnsov�����T���'�'�.vv�
Name: ��V1G� �D 5��,�.i� S Email: i--rra��a. ��ia �.� � c����Cai (�a x �c� �'�
Name: C; ;t(' "t �.��il!'-��,��.r Email: � k, i V�e��(E�e.rG� �..i�uc��t-t�.�ft� x�0 r'�
Name:
i3 - BIS, LLC
333 industrial Park Road
Piney Fiats, Tennessee 37686
1-866-514-5192
Email:
v.2.1.21
Page 7 of 9
ATTACHMENT C
Client Information
Tax ID number: 42-0959452
Please fill out and return the foliowing questionnaire to BIS via email, mail or fax to:
OnlineServices@bisonline.com, or Fax 866-855-5999 BIS 333 Industrial Park Road, Piney Flats, TN 37686
Entity Name: City of Fairfax I Office Hours: ,�, �„�� o� �+..�^�,7.j�
Mailing Address: t - ��
City: Fairfax State: IA
Phone Number: 319-846-2204 Fax Number: Pdfi� 31t����� ��
Office Contact: Tina Rosekrans Email: trosekrans@cityoffairfax.org
Computer Vendor/ Administrator Name:
� ���- S-����s� �
Type of ystems Online: Payments
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
_ : ; ►►
Zip Code: 52228
��
Phone Number:
�� %°`g'�i��-�0 �
v.2.1.2i
Please fili out each bank account your office uses and specify the office. (Ex: Tax Collection, Courts, Sanitation.)
Page 8 of 9
�I� Internal 11se: Thss sec�oon rr,ust be comple�ed b� the accourat repo
BIS Sales Rep: Brandon Parker MPA Required: Yes
*►f Fl�1P�i I.� r��uiw�cl the foU�snra�►� s�u,�� b� �ns�nrer�d
Customer Type: New Customer Service Type: Online and Counter
Department: Web Fee Pay Merchant Type: First Data & Amex
Please complete and return to your sales rep or to our Accounts Receivable Department
at accountsreceivable�bisonline.com
General Information:
�illin� Pr�f�rer�ces:
❑ Paper Billing to the Address Above C�-Billing to the email address(es) below
Email: Email: `ir�� x�� a,�� ir 9 X�c�
Email: Email:
l yYl�cc...��rh���?
Au orized Individual (Signature)
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
%asu�r' `�/�-��
Print Name Title � Date
v.2.1.21
Page 9 of 9
ATTACHMENT D
Banking Change Request Policy
Banking Changes
BIS will only change banking information when the request is received from and verified by an authorized
account administrator that has been designated by the CLIENT.
CLIENT must designate at least two (2) staff employees who are authorized to request a Banking
Change. For security reasons, only authorized designees requests will be processed.
Any and all requests for Banking Changes must be submitted via support request to BIS via email, fax or
mail:
• OniineServicesC�a.bisonline.com
• Fax:866-855-5999
• Mailing Address: 333 Industrial Park Road, Piney Flats, TN 37686.
All requests once received by BIS will also be verified by phone.
Banking Change Request Procedure:
• CLIENT must obtain a Change Request Form from BIS
• CLIENT must email, fax or mail the Change Request Form to BIS Support
• BIS shall verify the request information by calling CLIENT's authorized account administrator.
• Once verified, BIS shall process the Change Request
i3 - BIS, LLC
333 Industrial Park Road
Piney Flats, Tennessee 37686
1-866-514-5192
V.2.1.21
Please list the authorized personnel:
i� � ����� �� ��> > � �ii�� � , �, ,��� �� � ��i�� �����
„ .�� , � � ��
PROCESSOR
INFORMATION:
Name• i3-BIS, LLC
Address: 333 Industrial Park
URL: ��'�'•hisonline.com
Customer Service #: .�FF-514-5192
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 yourAgreement with Bank and/or Processor or the contents of yourAgreement
withTeleCheck and/or its affiliate,TRS. The following information summarizes portions of yourAgreement in order to assist you in answering some of
the questions we are most commonly asked.
I. Your Discount Rates are assessed on transactions that qualiFy for certain
reduced interchange rates imposed by MasterCard and Visa. Any transac-
tions that fail to qualiFy for these reduced rates will be charged an additional
fee (see Section 18 of the Program Guide).
2. We may debit your bank aeeount Erom time to time Eor amounts owed
to us under the Agreement.
3. There are many reasons why a Chargeback may occur. When they
occur we will debit your se[tlement funds or se[tlement account. For a more
detailed discussion regarding Chargebacks see Section 10 of Card Processing
Operating Guidc or sce thc applicable provisions of thc I'eleCheck Services
Agrecment.
4. If you dispute any charge or funding, you must notiEq us within 60 days
oF the datc of the statement where the charge or funding appears for Card
Processing or within 30 days of the date oE a ieleCheck transaction.
5. TheAgreement limits our liability to you. For a detailed descrip[ion of
thc limitation of liabiliry sce Section 20 of thc Card Proccssing Gencral Tcrms;
or Sections 137 and 1.48 of the TeleCheck/TRS Services Agrcement; or
Section 7.11 of the TRS Services Agrecment.
6. We have assumed certain risks by agreeing to provide you with Card pro-
cessing or check services. Accordingly, we may take certain actions to mitigate
our risk, including termination oE the Agreement, and/or hold monies otherwise
payable to you (see Card Processing General ierms in Section 23, Term; Events oE
Default and Section 24, Reserve Account; Securiry Interest), (see TeleChcck/IRS
Services Agreement in Sections 1.1, 13.2, 1.3.9, 1.5.2, 1.5.7, 1.7.Z, 1.7.10, 1.8.2,
1.8,8, 1.28, and 1.29) (sec Section 7.4 of the TRS Services Agreement), under cer-
tain circumstances.
7. By executing thisAgreement with us you are authorizing us and our Affiliates
to obtain financial and credit information regarding your business and the signers
and guarantors of the Agrecment until all your obliga[ions to us and our Affiliates
am satisfied.
8. The Agreement contains a provision that in the cvent you terminate the
Agreement early, you will be responsible for the payment oE an early termination
Fee as set forth in Part III, A3 under "Additional Fee Information" and Section
1.58 oE the ielcCheck/TRS Scrvices Agreement.
9. If you lease equipment from Processor, it is important that you review Sec-
tion 1 in Third Party Agreements. Bank is not a party to this Agreement, TH15 IS
A NON-CANCELABLE LEASE FOR THE FULL TERM INDICATED.
10. Card Organization Disclosure
Visa and MasterCard Member Bank Information: Wells Fargo Bank N.A.
I'he Bank's mailing address is 1200 Montego Way, Walnut Creek, CA 94598, and its phone number is (925) 746-4143.
Important Member Bank Responsibilities:
a) I'he Bank is the only entity approved to extend acceptance of Card
Organization products directly to a Merchant.
b) ihe Bank must be a principal (signcr) to the Merchant Agrecment.
c) The Bank is responsible for cduca[ing Merchants on pertinent Visa
and MasterCard rules with which Mcrchants must comply; but this
inEormation may be providcd to you by Proccssor.
d) rhe Bank is responsiblc for and must provide setticment funds to
the Merchant.
e) ihe Bank is responsible for all funds held in reserve that are derived
Erom settlemcnt.
Important Merchant Responsibilities:
a) Ensure compliance with Cardholder data security and storage requircments.
b) Maintain fraud and Chargebacks below Card Organization thresholds.
c) Review and understand the terms of the Merchant Agreemcnt.
d) Comply with Card Organization rules.
e) Retain a signed copy oF this Disclosure Page.
fl Yra�u reu�ixy cla�rvrorl����i� "`�ras�b [��::���c1;u�aue�h��'" Wi��wrz �'p,�a� rv�F����}��� ���:
l�tt ��lAra�� �r��,��u.c.c���uu/a�ti�.a��:�x�antwds� �x��krwu���a�b�ams��^�nilmtirr,s�:w Hmra����i
g) 1'c�ix caarr�r� c4ivcM�arlu,a,�l ���ti�rt�r��r�91;�,�;�nJ.��ati.rra�"' S's�°��+�ae fvID�5t�3 t.a�x��B's website at:
9artrpr.r"r`��� vv �n��tr:��r„�v�s�i,� �az�ltaMlraa� a��;9ra���tA'w�u����g��vhlaril��:a�"�'�t.d���G'I,
CITY OF FAIRFAX „�i;i�iioii�oii����/���i
Print Client's Business Legal Name:_„_ _ � ,.,,,,�; .. � �,�m��� ��, �_.����.��.-....— -.
By its signature below, Client acknowledges that it has received the Interchange Qualification Matrix (version IQM.MVD.S I I.I or m �,,,,,,,,,,,,,,,,,_,)�
and complete Program Guide (version RSAWT(TCK)1405) consisting of 54 pages (including this con£rmation).
Client further acknowledges reading and agreeing to all terms in the Program Guide, which shall be incorporated into Client'sAgreement. Upon receipt
of a signed facsimile or original of this Confirmation Page by us, Client's Application will be processed.
NO ALTERATIONS OR STRIKE-OUTSTO THE PROGRAM GUIDE WILL BE ACCEPTED.
Client's Business Principal:
Signature (Please sign below):
�� t;'��� ���»�.- � �. �;J �'���p�' `��f w� � .... ,...... _..� CITY CLE.�...,,�'�. SURER�.__.w.� � .� �� � �����f: �° "
X '��=,-; ° � "".
� Tltle ���e
�"�d�%�x� STIMSON
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Please Print Name of Signer
Flats, TNa 37656
RSAWT(TCK)1405 54
MERCHLI►NT PROCESSIN"G /�PPLICATIOIN 14ND AGREEMENT ', (Page I of s)
-� '.. COM�PLET�.E SECTIONS 1-14�.
Clfent
(vour eusiness �eGn� ��rrn��: CITY OF FAIRFAX
I� �� �� � �il ��M'�� or
Provide DBA/outlet Name: CITY OF FAIRFAX ONL
`ro�r� w.�a. eox)
�d� ' : 300 80TH STREET COURT
Your Business Phone: ($66i 514-5192
Your Fax Phone: ��6� 855-5999
Your E-Mail Address
(Required) �iC7��p'Y@SB�Y�G�"� Q��DI:�COf"rii�1�.`.��JYp71
Store #:
First/Last
Contact Name: JARED SHIPLEY
Suite #: �p�y,' FAIRFAX �����a IA �"�� � � 52228
1ffiSame as Business Phone or
MerchanYs Customer Service Phone:
Select One for
Retrieval �Cequ�SR�i ❑(02) Dedlcated 24 Hour Fax ❑(�M�) No fax; mail �I �(3�a) elDs
Your Customer Service
E-Mail Address: OtIIi�V��@M"SPMCB��b���C��li�lllB.COfil
��r��� � �� https://www.cityoffairfax.org/
❑ SMS Texting ❑ I Agree to receive SMS Texting Cell Phone #„� � �
. . . • . . . . , . . . .
YourTotal Cash and Credlt Sales: Estimated MC/Visa AverageTicket/Sales Amount: � 50.00
�.,,
(For au oudets) � `�'���'����.. 50.00_
Estimated Dlscover Network Average Ticket for this Outlet: $�„
Total Annual MC/Visa Volume:
(ForAll ounets) ��,,,„� �� ��%� ,, Estimated American Express Average Ticket for this Outlet: �-_ _,,,, .. w...
Total Annual Discover Network Volume: �N Annual MC/Visa Volume for thls Outlet: (ForMu/nple outlets only) $—. �� ��,�... ����.�:
(ForAllOutlets) $ ���"����... ��,i�i�, �il(�
Est. Discover Network Annual Sales Vol. for this Outlet: (For Muttlpie out/ets onry) �� �;„ „�.�..
Total Annual American Express Volume:
(ForAllOue/ets) � w,.,.... �,,.,....... Est. American Express Annual Sales Vol. for this Outlet: (ForMu/e/pie outlers Onty) �_ ,,m,,,�,,,.
TeleCheck Annual Revenue: � �_.,,,,,,,,,,,,,,,,,,,, �n HighestTicket Amount: �� ..........._
C�MC/Visa ✓ Discover Network Full Processing ❑ Global ePricing (for eCommerce merchants on/y)
❑ American Express
OnePoint/Full Servlce (EDC) ❑ American Express ESA / Pass Through: _ _ _ _ _ _ _--_ or ❑ Existing SE # ......... ..... . ._ _ _ _........... _. — —.
American Express Cap#__ _____ Franchise Name: �,,, . � � � �—�
Check one for ESA/Pass Through: ❑ Split Dial ❑ Single Settle ❑ EDC ❑ PIP ❑ Reverse PIP
❑ Debit Package ________ ❑ EBT SNAP / FNS # (XREF): ,,,W,WW,,,_ _ _.�.........�_..—.
, . . - . � _ ._ , . .
State Mo/Yr
Incorp. �� Started: 01/7900 ❑ Sole Ownership ❑ Partnership ❑ Non ProfltITax Exempt ❑ Public Corp. ❑ Private Corp. ❑ L.L.C. 1�Gov't. ❑ Federally Insured
Check one: TIN Type: � EIN (Fed Tax ID #) ❑ SSN D&B #: �,,,,,,,m,,,,,,,,,,,,,,,,,,,,, ,.. ... No. of Employees: 250
� �„ . 9 g p� �g "� ( Pert IV'„ Sectlon A 3 of ypur Progrem Guide for further nrrPaarmat�asr�.)
�.� � � , .. ...
N�O�TE� F�ail�ure to ��� �� �r�� d�n�����rwMa result in a withholdln of inerehant t�antYkaa �� S 7 �z�taan�. See �ww� � ,_
�:�" g� "��,I���-��lt ers on urincome mx retum) ❑ I certlfy that I am a forelgn entity/nonresldent alien.
CITYOFFAIRFAX � 42-0959452 (n�ekea,pfeeaeattachlRSFormW-8.)
Mag Swipe %+ Keyed Manually 100 /= 100% Product/ServicesYou Sell GOVT $ERVICES�NEC � � �
POS Card Present (MAG Swipe and/or Manual lmprint) %+ Mail Order/Direct Marketing %+ Phone Order %+ Internet 100 °/, = 100%
DO you use any third party to store, process or transmlt cardholder data? ❑ Yes � No (Examples include, 6uf not Ilmlfed to web hoating companies, Elecfronic Data Capture, Layalty programs)
If yes, give name/address:
Please identify any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests: „ � �_ .�
Social Security #
CYNTHIA STIMSON
Home Address
333 INDUSTRIAL PARK RD
Owner/Partner/Officer Name
01 /01 /80
City �
PINEY FLATS
D.O.B. Socfal Security #
Home Phone
(866) 574-5192
State Zip Country
TN 37615 I USA
Home Phone
% of Ownership
% of Ownershlp
IK��anflam.:V� +6���+9
�,�,p.�� p��,��$,� _ � City I State I� Zip I Country
. , . . � , . . . . . . . . .
�BA Name: CITY OF FAIRFAX ONL _ �oc. � 1 of , 2
���14"J� "CCGS ti'4�Y� . . , : ,� _ � . t�I�Gar ��ara1�r��1 i�1
Network: � (206) CARDneN ❑ ( ) Nashvllle ❑ ( ) Buypass ❑ Other: ., Specify Security Code: ( j
Rental • Pw��cR�as� Retail • Restaurant • MOTO/Internet Unit Price For Customer-Owned
Customer-Owned
EquipmentType Lodging•Supermarket•CarRental w/oTax Equipment
Lease �e1��Ck ara��h �TY IP (i.e.,Terminal/VAR/IMernet) Quick Service Restaurant • Petr Model Code and Name and S&H Treck/Version/Serial #
R P J� 1. 1 ❑ VAR R Re MO�/I L S C OSR P INFUSION V 3.50/MONETRA S 0.00
R P C L ❑ R Re MOTO/I L S C OSR P $
R P C L ❑ R Re MOTO/I L S C OSR P $
Shipping and Handling: Standard $ 19.95 Overnight $ 35.95
NOTE: d�n,+� Special Instructions must be included on About Merchant's Business P�a��
Installation/ ❑ MAG/MIG to Train ❑ Sales Rep. toTrain (Recelve training via phone, 1-B00-558-7f01 Opt #1, M-F8:00 am-f0:00 pm EST & Sat. 10:00 am -2:00 pm ES'�
Tralning: ❑ No Merchant Training ❑ Installer/In-House (Check training via phone, 1-800-366-1054, M-F 8:00 am -10:00 pm EST & Sat. 10:00 am -2:00 pm ESn
FIrsULast Contact Name: �ARED SHIPLEY Contact Phone #: �866) 514-5192 BestTlmeTo Call ❑ am ❑ pm
Imprfnter Purchase: ❑ Yes fffi No If Yes $29.95 x �ty: _�' ,,,,,,,,,,,,,,,,,,,,,, ,,,,_.m (w/oTax) Wlreless Provider: ❑ GPRS Cingular or ❑ Other: � �m� _
Check one: ❑ Gateway Solutions ❑ Dial Solutions ❑ First Data Global Gateway (FDGG) ❑ VSAT*" ❑ Frame ❑ Other:_��,,,,,,,,,,,,,,,,,,, ❑ IC Verify Serial #_ .,,,,,,,,,,,,,,,,,,,,,,,,,,,
VAR/Internet/Software: Name: ,
INFUSION V 3 SGDJMM1�1'�1��F�A (Nashville Only: Product ID # ... ...., vendor �� # )
NOTE: *`*Requlres separate agreement between VSAT Provider prior to implementation of this telecommunications protocol.
LEASE COMPANY: (04) First Data Global Leasing Lease Te�m: Months Annual Tax Nandling Fee: $ � 0.20
Monthly Lease Cha�ge for This Location: �,,,,,,,,,,,,,,,�� w/o taxes, late fees, or othe� charges that may apply.
*See Multiple Loca�ions form for the Monthly Lease Charge for eaeh individual loca�ion. See Lease Agreement fo� details. CS
This is a NON-CANCELABLE lease fo� the full term indicated. Client Initials:
7 FiAT RATE / IC PLUS '/ TIER PRICING(SCHE�ULE
t��r�-T�rx�Fa�aa ��a��:.
Application Fee (Non-RefundableJ (247) $ 0.��
Reprogramming Fee (31A) $
Debit Set-up Fee (31 B) $
Miscellaneous Fee (31J) $
•Equipment Purchase (ACH) $
Other: __, ................. � ) $
Total Amount $ w/o tax
'You will be charged ihe applicable S[ate/Clty/Local
Sales rax.
Sta�t-Un Fees
Internet Set-up Fee (30R)
FEEPERTID #OFTIDs TS7�TFt�..
$ x = 5'.......�..
� �"3p',��h�' ',.� F��s
FDGG (31 Z)
FEEPERTID #OFTIDs TOTAL
$ x = $
Internet Service Fee (394)
FEEPERTID #OFTIDs TOTAL
$ x = $
Global ePricing MC/Visa
Service Fee (897, 898) %
NOTE: C/ient shall be subject to any '
fore/gn cunency exposure !n connectlon '
with Global ePricing transactions.
Com liance Service Fees
❑ Annual Fee (32Q) $ �.00
or
❑ Qua�terly Fee (33R) $ 0.0� '
PIN Debit 7�ans Fee
(018, Key OS90, Key 0-593) $
(p/us ihe appllcab/e Nehvork Fees)
—OR—
�undled Debit
(PIN, V/MC/Disc Non-PIN)
Debit Sales Discount (120) %
Debit Sales Trans Fee (124) $
TY�:��..d.�'4�e� ��cs
I�akresr�resk�FGiisG, MC, V, Amex, Dis,
crp�c� &u��a, oaR, osi, o�i, a3s, L79) $ 0.05
Fraud Flex Detect
Base Level Offe�ing
Setup Fee (L32) $
Monthly Fee (35A) $
Transaction Fee (L35) $
Mobile Pay
FD Mobfle Pay Setup Fee (31H) $
Entltl@MelltS � FD Mobile Pay S-User
Monthly Fee (398) $
AUTXOXIZATION
American Express 0.25 MDMhbile Pay M-User
ESAlPassThrough (10P) $ y Fee (396) $
Note: See Pa�t IV "Additional Impo�tant Information Page for Card Processing"
in Section A.3 for early te�mination fees.
Chargeback Fee (205, 725, 20L) $ 5.��
MC Cross Border Fee USD �sos� 0.65 i
Visa InYI Service Fee (pZp) 0.65 i
MC/V/Discover Nehvork/American Express• 0.75
VoiceAuth (70B,70E,10K,100) $
esr (�ae, �si, ozx, �sH� g 0.10
ays (aos, aos, ao�, aos) $ 0.10
TransArmorToken & Encryption (12E) $
ACH Reject Fee �40�� g 25.00
Discover Network AVS (o�a, o�s, o�c, o�s) $ 0.10
Batch Settlement Fee (227) $ 0.�0
MC/V/Discover Access Fee (505,
Discover InYI Service Fee
Discover InYI Processing Fee
Visa Zero $ Verification
Visa Misuse of Auth
Visa Zero Floor Limit
Partial Auth Non-Participation Fee
MC Processing Integrity Fee
MC US Acct. Status Inquiry Service Interregional Fee
MC US Acct. Status Inquiry Service Intreregional Fee
Other: �............�........�..�..�..�..........�.�.�.�.�......�..,......-
14, 526) $ v.va � � �
�22H� 0.55 y, '
�zzG� 0.40 �
��ov� g 0.025
(oa�� g 0.045
(oaq $ 0.10
(12D) $ 0.�1
(oaF� g 0.045
����� g 0.03
(itH) $ 0.025
S
Other Payment Fees
American Express ESA/Pass Through Fees:*
•'Amex Discount Rate: % ❑ Amex Monthly Fee: $ 7•95
(Flat Fee)
Amex Transaction Fee: $
*Billed separately by Ameriean Express.
**Retail & Restaurant merehants will be eharged an additional
0.30% for non•swiped American Express trensactions.
���'�d�����'Yr����'���s,.'�✓+'� �m.,.�.,;.,.`?
. , . . � , . . . . . . . - • . .
Interchange Schedule Verslon:
CITY OF F
AIRFAX ONL PricingType: O 2 0 LLoc. � of 2
DBA Name : ................. ... .. .... .... .� ...................._�
�tSr�,W�' 1"�k� 1�ti�45' . _ . . . . . ,, . E�t��c�r F��15[7� e�
DISCOY�It FeeS (Besed On GrossTransaction ✓olume) ��'.
Accept all MasterCard, Visa and Discove� Network hansactions
(presumed, unless any selections below are checked)
�,���Edk"�'�m�d �k�c�s i�aql�c�, 'I�d� d1cCm tg�iz+� I" ��r.� FA�tpprark' ad���e�,�',�+�.
❑ Accept MC Credit trensactions onlv ❑ Accept Visa Credit transactions onlv ❑ Accept Discover Network Credit transactions onlv
❑ Accept MC Non-PIN Debit trens. onlv ❑ Accept Visa Non-PIN Debit trans. onlv ❑ Accept Discover Network Non-PIN Debit trans. onlv
5e� S�c4i�n '�.9 pY th� �rn�pr�m �uuade Pnr detail� ��g�rdi�� �imYted �cceptan��. Xtwu �ara res�cwrasible B�r dt�t&�gufahlrrc� �a�:s�iR fra�rr f�ara-PIC�1
C3�r'�it ��r�N�, Ev�sti vC y�u hs�v� a�r�eed to Nirni9 ycau�' a�c�:pt��uc� �f ��rtair� �rd'� �s a�utl�►�ad above, yau �nws4 cc�nt��a�u� 2er a���pt �II for�igrr
Iss��cY caads„ �I�e�ir�r Cr�sdi4 tar h9�n-�"�� ����. IY y�ru a�re� to Mir�7� �a�ur a��c�pt�n�z�; tira � paridcul�r t�y�ae cr� cart� �rrd, �nrh�4h�r �ntenf�c�nafl'y
re�r^ 6�a �rr�ar„ �ec��art ancrtl�er ty'� �t kr�r�sa�ct�aamx� �^Ra�a r��ultdn�g t��rn�a���l�rrr will udowrna�waa��; tc� t!`u�: h�g4���st, c��s� arkt���civ�rwg� pfu� �h� appC�c�mkale S4I�aa�_
Qtr2iliil�r! SurcB�a��e ��e� S��C4d41Tk "I�.B ra1 tFw�s Pra,g;re'mi Cau�r���.
Pricing Method: (Selecf One)
OUALIFIED DISCOUNT RATES
MC/VisalDiscovar Network
Credit Discount Rate
� American Express OnePoint��
* Credit Disoount Rate
' MC/Visa/Diceover Network
''����.. Non-PIN Debit Discount Rate
A�IDAUALIFIED DISCOUNT RA1
MC/VisalDisoover Network
* '����.. Credit Disoount Rate
' MCIVisa�Diseover Network
MC/Visal I......... MCMsaI II Trmn�sac�#�o�n �er���
Discover Discover (Applles to MC/Vlsa/Olscover Network 2-Tfer
Network NetwoAc and
2-Tier 3-Tier MC/Vlse/Discover Nehvork 3-Per ONLYJ
MC/V/ Discover Network Oual Credit
eoa, no► __. r _... � ..........� hans Fee �wi,00z,00s,00s� �o�s,ois� $
�� - i �
J
ey 0-570) ,� �. , ,� .
MC/V/ Discover Network Oual Non-PIN Debit
854, 964) 9« `Y hans Fee (130,131,134,135) (787,7BB) $
e not aooN ro MC/V/ea/Dlseove►2Tisr)
(810,814,990)
Non•PIN Debit Diseount Rate (870, 874, 96B) ��,
NON-0UALIFIED DISCOUNT RATES
* AJ,9C/VisalDiseover Network
Credit Diseount Rate (820, 824, 994)
MC/Visa/Diseover Nelwork
Non•PIN Debit Discount Rate (BBO, 864, 978)
* P�r� d1a dckw�'�p�G1� i�` ��at+�de�11 '�C �� �wm�m
MCIV/Di�cover Nlwk Auth &� Return 7�ans Fee
(10A,10D)(002,006)(131,135)(1W,016,788)
MCIVisa/Disoover
Networkl
American Express
Discount Rate
�
�
----� _%
� .............................
American Express OnePoint hensaotion Fee � ��"�� � , � ,� ����j � , y � i��� " �°
Non-Qual Surcharge Fee (30D, 20N)
�'�a�.�a�ad�fP�o,�..lnferohangepass-throughfees,seeSectlon18.1) 299 %
Applies to Non-qualified MC, Vise, Discover Network, � � � �� Ij — •��p�-
Amer. F�press Credit, and/or Non-PIN Debit Trans. i, ,n, � �I
t'Retail and Restaurant merchants will be charged an additional 0.30% for non-swiped American Express t�ansactions.
MCIVisa/Disoover
Networfc IC Pasc Thru
You will be charged the
appliceble interchange rete
from MC (564), �se (549), or
Discover Network (527), plus a
MC Asseasment Fee (273) of
0.11 % [MC Assessment Tran
Amt >=$1 K (23�, an addi-
tional 0.01� will be charged
per MC settled credit card sale
au�uen t;#as 4r.uo�s�a-catan �anc�ar�t
equals $1,000 or greeter], a
Visa Assessment Fee (274) of
0.11 %, or a Discover Network
Assessment Fee (234) of
0.10%, plus any other fees
indicated on this Servlce
Fee Schedule.
�
�
g .05
(8=) TE4ECHE�CK R'ATES; SER:VICE 'FEES�:; AND��'� SET ����UP INFOR'�.MATI�ON
Your Head Office/Bill To Name: 0 First/Last Contact Name: I� Phone Number:
Address � Suite # � City: � State: I, Zip: � Your Fax Phone:
❑ TeleCheck Auto Settle Time: hh ET (Must be at least 1 hour after Card Auto Settle Time)
v � , , ,.. � ,
� u-,� r, � � � � r
�� �� � � ,
, , , � , , , , „ , v�, , ,, n � ,, � �, �� �,, , r , � ��� � �,,� ,„� , ,, , , � �< <U , Ur ��� r i, , � N r i
� irl r , � � � � .i p iXi ,,, Vi � . ., , � � a, � .. u1 ! ,,, p ,,, � r1 ! � , aG � 1 I (l � I l / � / lll
.� li� .. a�� . �� , f 11 I I �/ � r „���
II 1 ��, � r f � f 1 1 ���1�11r�rr�rrr�r�°����r���������r�����,�y������rrrr�r�(��������rr�i�i�iiiir������r��rc�rr��,����������c
�i��1�ll�i��'��`�i!�I�I�fdl��'�ii±��'G�?����f"���'��1��5�����lti��l�"��'�d�i����'�,,,i�����r���„��,�i����„�(�,��:�a,u,��n ��,���" �/� �������r����y�,'����� ,,,� ���,�,��f�,�,�,�i.�1z,11�,�1������.�1
Funding Report: ❑ Bill To ❑ Location Delivery Method: ❑ E-Mall ❑ Fax ❑ US Mail Existing Subscriber No.: �,,, ,,,,,,,,,,,,,,,, �,m _
Contact Name: _ ____ ,,,m..� ContactTelephone #: .. 6.......... ..�
Report Fax #:
MC/V/ Discover Network Mid-Oual Credk
���„�, hans Fee (611,672,615,616) p17,718) $
MC/V/ Discover Network Mid-Oual Non-PIN
�'�q�„ DebitTrans Fee (140,141,144,145) (791,792) $
�� MC/V/ Discover Network Non-Oual Credit
% I II�« hans Fee (627,622,625,626) (721,722) $
����. MGV/ Discover Network Non-Quel Non-PIN
% I ..... ........ .��. ' DebRTrans Fee (150,151,154,155) (795.796) $
Report E-Mail Address:
Batch Closing Options: ❑ am ❑ pm Fo�mat: ❑ CSV (E-Mail only) ❑ PDF
t �� ,
,� � v d, �, u � �r,rr ,, ,Y„ , . aua„ ��,, , �u„� �, � {,.�� , , � r � � � i r � , r
«�� �tt � ry u,u�N ��,w �� �r�,rr«�� u,� � ���e w �r� �� , �N� � ,u �� � ��, � ���� � � � �rr r �� n , r� � t � �` � �11���»ft ,r
� i 1 1 � �, � � I� I, � r�l,� � r� l rE l ��' IU,III�VI�� 1���0111f�f111111�'�;�1[P,������,�/�,�'�trll�lf�l/�//�1I1/,l�l�G�lIYJJ
��r1�'r�(��x�!���;�����+�����J�'�'�l�����"������ff�?��"����r��w.�,�w,���,��V�xxx�(Gx�����,� �i�,,�,�i�'m,�r�����ue�,Jld����l,����f��m,��i�`�v�r��, �,'���A,,,G�����,'����rx�,JJG��,F liu„i��Ill�lflJ�����'�Y�'� �.�Pl
Funding: ❑ Per Bill To ❑ Per Location
ACM Credits to TeleCheck ', ABA 7'ransit #: �_, _ ��, ._—_�,._., .... Account #: ,e.w �
by Subscriber (For Invoice Payment): ,
❑ Same as above or ❑ Same as above or
Debits/Credits (Settlement to Subscriber - , mm m �' — � n IT � � � •
by TeleCheck and/or Frenking Information: ABA 7Yans�t #• Account #• , ..,,_
Special Instructions which are part of this Agreement: .. ���.�..� .............. .�...� v�_.......................... ..............�
Please note on sepa�ate funding check or bank lette�head the designated TeleCheck Service. A sepa�ate funding check o� bank letterhead/logo fo�
TeleCheck Se�vices is NOT required UNLESS Merchant will be using different banking account�s) fo� TeleCheck Services.
Client Initials CS
. _ . . . . . . . . . ....
.
DBA Name: CITY OF FAIRFAX ONL� �oc. 1 of 2
TeleCheck Services, Inc.
, � P.O. Box 4514
` Hous[on,TX 77210-4514
��li i m uuoo�ufiui '' �� 1-eoo-366-1054 # of Physical TeleCheck Locations:
Lockboz Check To��
WARRANTY ❑ ECA '❑ e-Deposlt '❑ Lockboz ❑ Pro27 ❑ ICA• ❑ CBP"' ❑ Peper ❑ Cashing ❑ Mall Order ❑ COD Set•Up Fses
Average Check Sfze $ $ i $ $ $ $ $ $ $ $ I
Monthly Check/
Call Volume $ ' $ $ I $ $ $ $ $ $ $ i
!��
Inquiry Rate .....�.�..... .� ��� � � � .._ ......... ....n.% q ...... ........� . %a� % % .... �___-/ �i�,������a � r , �
Transaction Fee � $ $ $ � S $ $ $ $ $ S ��� ���� � �i.�ol�
Set-Up Fee $ $ $ $ $ $ $ $ $ $ $
nnonthly Minimum ,$ 25.00 g 25.00 $ 25.00 $ 25.00 g 25.00 g 25.00 g 25.00 $ 25.00 g 25.00 g 25.00 I��� ��
CROC / Voice Auth Fee ,$ 2.50 g 2.50 g 2.50 g 2.50 j � g 2.50 g 2.50 g 2.50 g 2.50 � � �
Statement � � � � ��''
Processing Fee g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 �, ,
December Risk �
Surcharge 0.10 � 0.10 � 0.10 q 0.10 ��I 0.10 y � 0.10 % 0.10 g; _0 10 %, 0.10 � 0.10 y; ��ij� � a�
..�d
� ���,��,�, � j
25,000 $70o Personal � � '
Warranty Maximum $ $ $ $ $ $750 Gov $ $
❑ Face Amt. ❑ Face Amt. ❑ Face Amt. ❑ Face Amt. $ 2,500 $ 5,00� ❑ Face Amt. $750 Corp ❑ Face Amt. ❑ Face Amt �
Order Confirmation I �
Notice � $ fl �, � �', , �
TRS Collections ❑TRS ❑TRS ❑TRS ❑TRS ❑TRS ❑TRS ❑TRS ❑TRS
(see TRS Svcs SecNon 9) ,� ����...... Paper Onty � ������
Other:
/ �1
._____ �, � , - f�
_ $ $ $ $ $ $ ��� $ i $ $ $ � 1��
VERIFICAT�ON �oc�ox cneok Tcta�
❑ ECA ❑ Lockboz ❑ Pro21 O ICA• O CBP"' ❑ Paper ❑ Cashing I❑ eDeposR Set-Up Fees
Average Check Slze $ $ $ $ � $ $ $ $ � �� l l�
Monthly Check/Call Volume � $ $ $ $ $ $ $ $ ,,,, ,,,, �
Transaction Fee $ $ $ $ $ $ $ $ i i i1 �, , � -� l;
Set-Up Fee $ $ $ $ $ $ I S S $
Monthly MlNmum g 25.00 g 25.00 g 25.00 g 25.00 g 25.00 g 25.00 g 25.00 g 25.00 il � , fi`
CROC / Voice Auth Fee $ $ $ ,
2.50 2.50 2.50 �$ 2.50 g 2.50 � g 2.50 � i
�
statement Processing Fee g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 g 5.00 I 1 �b �
� , !
C�c2� neax Dollar Amount ,, , �, g 25,000 � � a � I j 1, .�� g 25,000 1;�
� � ,� � �� � �
� � (
���,���,� � �, � ` � , � ,1„N �
Order Confirmation Notice � � � t� � , �� �' 6 $ rl� , � � � fr, � �x,'
TRS Collections ❑TRS ❑TRS ❑TRS � ❑TRS ❑TRS � � ❑TRS
(see TRS Servlces SecNon 9) Paper Only ����, � '� J,��� �
� �- ��� � �� „� , � i
Other: ,. ...._.�.. __..... $ $ $ $ $ $ $ $ ) � '
See TeleCheck/TRS Agreement for definitions, war�anties, and any additional fees.
Note: See Section 1.38 "Damages" of the TeleCheck/TRS Agreement fo� early termination fees/liquidated damages.
�iaA111U'T �Q."�tlC 1��7"a" . . . � . � _ . • �3���u�� ���1ah�11��
"� ❑ ECA Ver"rfication with TRS ❑ TRS for Warranty (Non-Compliance Ifems) ❑ TRS Other (Including PaperVeritication)
IIIm „�� % of Item Amt. Recovered Retained byTRS: 20% % of Item Amt. Recovered Retained byTRS: 20% % of Item Amt. Recovered Retained byTRS: 2096
w�aa,r,r�v�r ��u,rnM,+m�.,, qmt. of Retum Item Fee Retained byTRS: 100% Amt. of Return Item Fee Retained byTRS: 100% Amt. of Return Item Fee Retained byTRS: 100%
NOTE: Stop payment checks due to dispufes over goods ar serv/ces must be returned to Su6scrl6er for resolut/on. Bank Auth: ❑ Yes ❑ No Remittance Frequency: Monthly
i����� �������� �� � J��r
M"ER"CHANT PROCESSING APPLICATION AND AGREEMENT (Pagesofs)'
,_ • •
� � '- � �" 1�0� P.4YMENT ESS=ENTIqLS �� ` ` `�`
PaymentEssentialsType: W� mmm .............__
❑ Web.com NOTE: 3 Domain Names are requlred if website is chosen. (Limif 37 characters per line)
Domain Name #1: �,,,,,,, �_ � �,,,,,,,,,,,,,,,,,, � � sufflx Requesced: ❑ .com ❑ .net ❑ .org Pick a Template:
Domain Name #2:
Domain Name #3:
as Contact Information inTell Us AboutYour Business Section or provide:
FirsULast Contact Name
�(Same asTell Us AboutYour Business Section or
❑ Same as Tell Us About Your Business Section or provide:
Shipping Address:
❑ Same as Contact Name or Provide Reporting Contact Name
Delivery Method: ❑ Ground ❑ 2nd Day ❑ Next Day Air
City:
State: � Zip:
❑ Same as Contact E-Mail Address oi Provide Reporting E-Mail Address
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�ervrtc,imza� p��gxam, w�Oieh th� �nfi�i�y maMy ke emral9e�l' tln pkP'� s�e�d�rl C�rd aer�p�4�,nc�s �rrogr�m� e�n� Ih� er�4�a� e��� M�r��ar8nai� 1h� a4gre�a�v�ent. By �ecapRCr�g k9ire J�mer���n �upaas� ��rcU Car th,e purr:9aa�
+�1 gc�r�ds ��tlfar w�nric��, +5r erkhtsa^rw➢�a in�d6tatYng iis i�tecrol'ian Tcw �� tre�urae9, PY�d an�ty pr�r��s t,er tie 6ound by the Agreement.
E4y t�ignVrn-a� �aqa�wu, eacM1 a� �kr� unr��a�4grt�d �u9�s�rYxe� u� �o-��C vu� A4ldti�tee �t rt�q�u�r9i �n� caht�i�� 9rmmu � caa�zcun,er r�apt�r0.�ng �gen�Yu ��rsan�l �nsY �Sute6ncc�e ccrnsurrueK re�asrrt�� 19 #hr� Ap�l���11+�tr tls appro��o-dil
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n�rudersi��eck Guriherenc�ne �gr��a iia�t �rAt raa�er�nc��, incl�ading �nkcc $nd c��a�w.�usv�r r�gar�rking ag�z�afles„ m�ry reN��q��r ��wY sc�rd �II p�rs�wn�l ar�� �wsqn�sa �r��6Br itnanc�a9 Y'rrtra�m���ra�w kaa u� arrd �ur A1fiiNfia4d,�.
�ach rai tlre �r�s�c�rs�,�s��d �amkN���xzr� u� �rrd �aasr A�dl9pte� ta pa�ru3'�Ye amc�nga� ��nc �ath�r �he 4ni�arr�u�ti�rn a�r�s�in�d 9n ihi� fihl�rchm�nt ��ocess�r�g l6�plle�tV��p and Agree�veer� ��red �rry i�di�rcn�tiary r��a�v��
4��un �I� ne�P�r�ru��a�, (rv�fiueNdn�g ����nks �rv�l �aa�n�umer ��parht'n,�p ��ge�rao�,�. 9t'w� aaa�r �aaqV�y Ca� �,�is�i�r ceeRsin Vniarrtrt�hic�n 4n �imdrar ��w v�r�dy y�our id�uttG�r twb�Gl� pze�c���B�g ,Ys�uM �rc�wsGirwt ap�VI��M1Vc�oro.
You fuRher acknowledge and agree that you will not use your merchant account and/orthe Settvices P�w Nlpega4 tre+a��zet6�r�o�, for travmple,those prohibited by the Unlawful Internet Gambling Enfmrcerta�nt
Act, 31 U.S.C. Section 5361 et seq, as may be amended from time to time, or those that prohitn8k prs�ceawdng �nd a�c�?pt�iraee aP Rr�p�ve�c4ions in certain jurisdictions pursuant to 31 CFR Part SCJP� et seq.
and other laws enforced by the Office of Foreign Assets Control (OFAC).
Client eertifies, under penalties of pery'ury, that the federal taxpayer identification number and corresponding filing name provided herein are correct.
THIS MERCHANT PROCESSING APPLICATION AND AGREEMENT HAS BEEN EXECUTED ON BEHALF OF AND BY THE AUTHORIZED MANAGEMENT OF CLIENT AS OF THE EFFECTIVE DATE.
Client's Business Principal: (P/ease sign below) (pROCESSOR): Fo� First Data Merchant Services Corporation and
Wells Fargo Bank, N.A.
XSi nature�V� ��'�� � � ����,�"+�"'�
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�rv� �i� ��E"���"i!fo!�w(�..��,.����i'�....... ....... ...... ..., Date:..74 , „..,..,,�,..�"� "�'--��.
Dete:
Tltle: ❑ Pres. ❑ V.P. ❑ Member L.L.C. ❑ Owner ❑ Pertner �(Other: C�� CLER�TREA: ApprovedTeleCheck Meneger� � ��
X Signature
Print Name
TitlO: ❑ Pres. ❑ V.P. ❑ Member LL.C. ❑ Owner ❑ Partner ❑ Other:
X Signature
AC11 Debit and Credit Authorization: Client authorizes its Fnancial Institution to pay and charge to its account by electronic fund transfer the amount due TeleCheck and/or TRS under this
Agreement and to accept all credits and debits made to its account by electronic fund transfer as a result of TeleCheck's and/or TRS' services. This authorization shall remain in effect until thirty
days after revoked in writing.
XSignatu►e ...�.e.e. ,.,.,.,., , . Pdnt Name/Title: .. ,,,,,,,,, ,,,,,.,, ,,.,,,,,.. Dete:
Authorized Slgnature on TeleCheck Account }or ACH
Fia�"A"�YT 7 �I}� '� �•�Y� � » . . . rc . E3&«�"a 1 �r�T ��i
In sac��a.�n�at ftror Pir.�k �wgs �Pu��harrt �c�ro+i��ss C�arp��5a�d�a�u,'WN�rNNs� Fk�r��u �msa�, �tl.�W..� �rnd ��n�rtctar� ��apaw��t�" �p��pCan�e roe, as ��pN&r:ta6ld„ Che �tigre�mei�t avadlrar dh� �apui�rrae�wt lie�se,4�rea�m�mk amddP�r
7eB��h�c�s17RS Sasrvie�rs Agraeeme�sC ar�d.�aar �rm�rVc�n �a�p�r�s� C�rd A�cept�r��c� A�rez;�ser�t, th�a u�oa�rsigra�d un�rsmdlkirsn�Vly guur��t�rns �r�r�cirmaus,r�; eaf Ihe Cdlarrt'� r�bmag�td�ca� und�r �Fa� Pa��r�a�in�
A�ra��m��rtl�, and p�ya^n�nt �F stN �uun� cfci� th�m��nd�r, z�rr�@ rn t�+�ver�¢ a�� dea��wY�,17er��iyr w��iu^� ��rkis� a� �Z1�ufq �rad a�r��s I�r Nr�dd�m�rlTy kNr� r�lhr�� ���i�s i�r arvy �ncA �d1 eutt��Km�� cEu� tic� Cll�n�
uort�M�� uaa��r [rP tNn� Pcra�c,�raVn� p���eeumea�t� I �uxrd�rst�arrc6 B�a�t th�� Ns a Gu�rewrty �4 ��rwx��rnC a�rati �zsrf �a4 ua�slq+�w��rorn� anrb th�Y"d�,"�dis �w�n�a �arrk, �.h., F'Yrs,a Ca��s �Iier�Fw�t Srorvw��� �Gs�r�aor�N&�sn, �Mnd �nro+�ri��n
Expr�,�s �rt� r�tNy�ng u�ip�awr t9�iY� �warar�ty dru krni�ar�r�� dratrs, �rs �agrptf�al5a�, Che A���eam�tsnt� t�v� �qwi�ema�trR Le��� A�re�rerent�'Yw�R�Cht�ekJiiiS 5�wvicres �4,�c���p�ut drec9 AaoierYean E;xg�r�sa Caand l�c�ep�ap�c�e
Agreement.
Signatu►e (Please slgn be/ow)� Signature (P/ease sign below):
Suffix Requested: ❑ .com ❑ .net ❑ .org
Suffix Requested: ❑ .com ❑ .net ❑ .org
Contact Phone �I Contact E-Mail Address
.�,._,n,.__.�..�..�..�.......��....,m„�, .... ...,,m,,,,,.,_..._. Date: �.w
.�,
ApprovedTRS Manager
IFTELECHECK SERVICES HAVE BEEN SELECTED, PLEASE SIGN BELOW:
Date: .. ..,,.�„„„
X... .,,,,,,,, „ an Individual „...,,,. ,,,,m„�,,,,, r�,,,,„,„„�,,,,,..... . ., an indlvldual
. ; . • • -
BankCode: 9 3 7 MerohantlD:________—_-- BuypassMerchant#: �,..�,.,.,,..,.__—_.�........µ,�—....��
❑TR ❑TU
�B'4 ��NT�P"' OF FAIRFAX ONL (24characters)
NAME
Area #: 3 8 Group #: 0 1 Servlce By Region: 4 0 0 0 District Code: _____ ISR Rep ID: ____ SIC #: 9 3 9 9
Check Assoa Code: _ _ _ ��� � ...�......... �.... , Current Check Vendor: �,,� ... .... ... �-..•.
F�r�tt��a�t Contact Name: TENESIA BERRY I Phone #: 423 467-�°�66
aen #: 051404464 � ppa #: 2030006654m „ � ,
❑ ATTACX A COPY OF FUNDING CXECK OR BANK LETTERNEAD�LOGO SIGNED BY A BANK OFFICER WITX TYPED ABA/DDA. MUST INCLUDE BANK NAME & ADDRESS.
Regional Office Received Date: MCC: 9 3 9 9 • MerchantT� e:0 0 0 00 0 1 0 • 0� 0 1��NCPT: 0 0�
� � �
Pricing Grld # FDSG0730 ❑ Special Pricing Model ❑ Association Grid �( Llnkback # 9_ 3 _ _ _ _ _ _ _ NRPT. _ _ _ _ _ �
�� ��p��y�� p�„ G A L L Office Admin.: �,, mmm....� n �,.,, m.,m ,,,,,,,, �� Card Rep. #: B V G Y TeleCheck Rep. #: ____
Print Sales Re Name: EHSAN CHAUDHARY m,,,,, Initial: Sales LeadTrackin #:
p• ���������� � � ��� � � � Referral Partner Lead: ❑ Yes ❑ No � �
NIERARCNY: If yes,
eank: 9 3 7 9 8 0 0 0 2 8 8 8 Agent: 9 3 7 9 7 0 0 1_„0 8 8 3 Partner Name: ..... _ �.. ...
Corp.: 9 3 7 9 6 0 0 0 9 8 8 7 Chain: ....� ..._..-- ....,..., .--- BuypassF�ID:----
�( Visit Not Required (Lic. Professional) 7. Advertising Name Displayed: 12. Proper License Visible (Liquor, Tax ID, etc.):
1. Zone: ❑ Window ❑ Door ❑ Store Front ❑Yes ❑ No, explain: �,,,,,,,,,,,,,,,,,,,, , ...�.�.
❑ Buslness Distrlct ❑ Industrial ❑ Residential 8. Approx. Square Footage: 13. Your Previous
2. Location: ❑ Mall ❑ Shopping Area ❑ Isolated ❑ 0-250 ❑ 251-500 ❑ 501-2,000 ❑ 2,001+ Processor: ,,,,,,,,,,,,, ,� � .,,,,,,,,,,,,,,,,,,,,,,, .��.
❑ Office ❑ Apartment ❑ Home 14. Your Previous Merchant #: , „
9. # of Reglsters: �„�,,,,,,,,,,,,,,,,,,,, �,,,,, 15. Check Reason for Changing:
3. Seasonal: ❑ Noh❑Yes, Mos.'n Op ration: Y� 9 Y
i e 10. Return Polic ❑ Full Refund ❑ Exch e Onl ❑ None ❑ Rate ❑ Service ❑Terminated
Mos. Open Between to 11. Do you have a refund policy for your MC/Visa/ ❑ Other: �,,.,,, .. �
4. External Facllity Description (# of Levels/Floors): Discover• Network /American Express• sales? 16. Do You Have Previous Processor
❑ 1 ❑ 2-4 ❑ 5-10 ❑ 17 plus ❑Yes ❑ No If yes, Check one: MClVlsa/Discover Network/
5. Merchant Occupies• ❑ Exchange ❑ Store Credit ❑ Refund Cardholder American Express Statements? ❑ Yes ❑ No
❑ Ground Floor ❑ Other: ,,,,,,,,,,,,,,, ,� If MC/Vlsa/Discover Ntwk/Amer Exp Credit, withln how 1�• Are customers required to leave a deposlt?
6. Remaining Floor(s) Occupied by: many days do you submit credit transactions? ❑ Yes ❑ No If Yes, % of deposit required:_ %
❑ Residential ❑ Commercial ❑ Combination ❑ 0-3 ❑ 4-7 ❑ 8-74 ❑ Over 14 days Time Frame for Delivery: Days
Comments to Credit Officer/Other Depository/Primary Savings
Account Number and Addltional Information �'+�i� Characters):
�
. . � . , . . . • • •
Statement Recap Information: (check one) ❑ 01 = OutletlDBA ❑ 02 = Outlet/Bill To ❑ 08 = Recap Only/Bill To �09 = Recap & Outlet/Bill To
���p�y�p�;p,�p���'��yp;'�Iq���;^ (checkone) �(Electronlc (Delau/t) ❑ Print and Mail StatementType: (checkone) �( Detail ❑ Summary
Statement E-Mail Address: (�e+a�a�rra�d� ��„ '� k1'�!'� ' I��WI � I� ��� �� 6� ..... .
Head Office/Bill To Name: FirsULast Contact Name: JARED SHIPLEY
Address: 333 INDUSTRIAL PARK RD City: PINEY FLATS State: TN ZiP: 37686 Phone #: B�� 514-5192
ON YOUR BUSINESS ACCOUNT (check one)
CHECKING STATEMENT ROLLUP: ❑ 0= Each Transfer �(1 = Deblf/Credit Grouped (By Category) ❑ 2= Net Transfer Amount Only ❑ 3= Net Transfer EOM Fee Combined
. _ . _ . . . . . . �iS1�i��� Irt
1. Processing mode: f�EDC: ❑ Paper Voice ❑Tape ❑ ECR ❑ PaperTerminal 2. Discount Funding: Daily (excludfng F/et RateJ or �Monthly
3. Funding will be processed DAILY via: I�ACH ❑ Bankwire 4. Bank will fund: fi�0utlet ❑ Head Office
5. # of Plates: Long ShoR 6. Fire Safety Act: �Yes ❑ No
� �..:., �,....,�...,,„„� ,. �■�e�,,,,...e D�n4n� M/wAnwL....a�• r✓n���io* fl Head (lffica n nrnar_ rwev-� maiiina information helow �No Welcome Packet & Supplies ❑ No Welcome Packet
Namn•
n.�.�.e,
8. Debit Bill Payment Transactlon Type: ❑ Internet ❑ VRU ❑ Recurring ❑ Call Center
9. �,di�i-��t�l T��^ro��r��l ��,���,�;�: (Check all that app/y to ensure time/y terminal programming)
❑ Auto Settle Time hh ET ❑ QSR-CR/SMT ❑ Retail Gas
r...:r��...� fConvenience/Small Ticket)
❑ BarTab
❑ Clerk /Server Entry
❑ Debit Cash Back
Delayed Ship Date:
❑ Dial Prefix: ❑ Dial 9❑ Other:
❑ Dlal Suffix:
❑ E-Commerce
❑ If IP ���, �.
(List Current Provider)
❑ QSR Print Option
❑ Involce Number
❑ Multi-Trans
(PC/Register/Sol[ware on/y)
❑ Retall With Tip
❑ Ship Method (Overnlghry
❑ Tip % Option
❑ Verify Amount Prompt
❑ Partlal Approval
❑ No Server/Ticket ID ❑ Purchase w/
Belance Return
❑ Remove Room # Prompt
❑ Standalone
❑ Remove Ticket # Prompt Balance Inquiry
Sponsoring Debit Network: ❑ NYCE ❑ Pulse ❑ Star
❑ Amex Prepaid Program
Preference (Choose One)
❑ Partial Auth
❑ Balance Back
❑ Other
PINPad,:
❑ DES Encryptlon
❑ DUKPT
❑ Access Code
# ... ....,....
Terminal Features: (conPd)
Key Password
Disable or Protect
Credlts ❑ ❑
Voids ❑ ❑
Forces ❑ ❑
Reviews ❑ ❑
Bal/Settle ❑ ❑
Auth Only ❑ ❑
Reports ❑ ❑
Tlp Adjustment ❑ ❑
(NOTE: Completing the Comments fleld will result In a 48 haur terminal programming delay)
� � � � � � � � � � i� A'�C �.,"�'" �N M�" �. �� L.+I�,'M � ,�,"1, 1', � �A''� Page I of 2 Loc. 2 of 2
Card TeleCheck
Merchant#:_—�_�......... �m.... ---.—_. u....... Subscriber#:-------- BiIITo#.—__.... ,....-- .�......,,. NB#:--------
Plea e attach F❑ee Sehedule(Os)hand/R AC��AP�CODEappropriate. Pricin T e: 0 0 1 M dlllerent irom originaq p►dlHerenr 1rom orlglnaq Store #: _ ��,,,,,,,
�( 9 YP
aaa #: 051404464 .... ........� �. � oon #: M2030006654 .. .�.. .... ...�
❑ ATTACX A COPY OF FUNDING CMECK Oii BANK LETTERNEAD/LOGO SIGNED BY A BANK OFFICEA WITN TYPED ABA/DDA. M T INCLUDE BANK NAME & ADDRESS.
. . • • : �NSSF�,9°a"t�1 k��
Client
��`� �w�N�u�� � �L ���+��� CITY OF FAIRFAX
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I�������u��'��a�q�t!���m�r;�: CITY OF FAIRFAX Contact Name: JARED SHIPLEY
300 80TH STREET COURT
Your Business Phone: �$��� 514-5192
Your Fax Phone: ����` 855-5999
Your E-Mail Address: (Required) q��'j���E
Suite #: ����= FAIRFAX �I ���� IA ���q� "�: 52228
��¢�nr� as Business Phone o► MerchanYs Customer Service Phone:
Select One for Retrieval Rr�s���st�: ❑(�Y�� Dedicated 24 Hour Fax ❑�U3) No fax; mail ]&((45) elDs
Your Cust. Service
Cf,��G�Q17�1�@.CO�I1 E-Mail Address: O�II�N�:��O"Wi����bf�tifl�lTi�.�t7T1'1.
����� �r�d�: htt s:tl�+urwvwr.�dtyrasifair6��,or 1
❑ SMS Texting ❑ I Agree to receive SMS Texting Cell Phone #: �,,,,,,,,,,,,,,,,,,,,,,,,, , ..�
. . . • . - . - . ` • • • -
'"�� ��00 Avera e MC/Visa Ticket/Sales Amount for this Location: ��_ 50.00
Annual MC/Visa Volume for this Location: S � ............._. 9
50 00
Est. Annual Discover Network Sales Vol. for this Location: $,,_ ����,,,,,,, Average Dlscover Network Tlcket/Sales Amount for this Location: $�,,,,,, .�.
Est. Annual American Express Sales Vol. for this Location: �, a,,,,,,,,,,,,,,,,,,,,,,,,,,� Average American Express Ticket/Sales Amount for this Location: $,,,,,,,,,,,,,,,,,,,,, � ................
TeleCheck Annual Revenue: �. � ..............._.
f�MC/Visa �/ Discover Network Full Processing ❑ Global ePricing (for eCommerce merchants on/y)
❑ American Express ( ) P 9 9
OnePoint/Full Service EDC ❑ American Ex ress ESA / Pass Throu h• _ _ _ _ _ _ _ _ — or ❑ Exlstin SE # _ .,_ , � ,,, � m .
American Express Cap # _ _ _ __ ,,,,,,,,,,,,,,,,.. � � m, _ _ _..._.. �...._ Franchise Name:
Check one for ESA/PassThrough: ❑ Spllt Dial ❑ Single Settle ❑ EDC ❑ PIP ❑ Reverse PIP
❑ Debit Package ........,. — — — .. .......... .........._, � — ❑ EBT SNAP / FNS # (XRE�: ........�.�— � . ... — —
._. . . . . ; . . .
Check one: TIN Type: �QEIN (Fed Tax ID #) ❑ SSN ❑ Federally Insured
NOTE: Failure to pp�swrtde accurete iniormetion rrna��+ result in a+�nkh��ltlfru� of inerchant funding per IRS u�a,gu�a�C���. (S,�at Part IV, Section A.3 of ycawr P��r�w�m Guide for further in�iarmsro�i�rn,�
p��yji�� ��,�; `��;3�p�� d��u�V���u�N�R��u� P:� ��!tlkA�'> ����M�� i����" ��!��#�'�������� ��❑ I certlfy thet I am a forelgn entlrylnonresldent alien.
I CITY OF FAIRFAX 42-0959452 (H�hecked,pleeseattacblRSFarmW-B.)
Mag Swipe 9� %+ Keyed Manually � 0 %= 100%
POS Card Present (MAG Sw/pe and/or Manual lmpr/nt) 700 °/, + Mall Order/Direct Marketing %+ Phone Order %+ Internet % — 100%
Product/ServicesYou Sell: GOVT SERVICES - NEC �..� � ............. � .. ......., ...........
. . M - . .
Network: ❑ (206) CARDnet• ❑ ( ) Nashville ❑ ( ) Buypass ❑ Other: Specify Security Code: ( �
Rental • W�"ur��r�at� Retail • Restaurant • MOTO/Internet Unit Price For Customer-Owned
Customer-Owned EquipmentType Lodging • Supermarket • Car ReMal w/o Tax �q�i��na�C
Lease 1e�rea�k �r�e! UTY IP �i.c.„ Terminal/VAR/Internet) Quick Service Restaurant • Petr Model Code and Name and S&H Tw�ck Y Vex�6crnP��rrd-¢I dk
R P� �' 1 O VAR
R P C L
Re MOTOlI � s c osR P INFUSION V3.50/MONETRA $ 0.00
R Re MOTO/I L S C OSR P
R Re MOTO/I L S C QSR P
S
$
Shipping and Handling: Standard $19.95 Overnight $ 35.95
Installation! ❑ MAG/MIG to Trein ❑ Sales Rep. to Train (Receive training via phone, 1-800-558-7101 Opt #1, M-F 8:00 am - f0:00 pm EST & Sat ]0:00 am -2:00 pm ES�
Training: ❑ No Merchant Training ❑ Installerlln-House (Check training via phone, 1-800-366-1054, M-F B:00 am - f0:00 pm EST & Sai. 10:00 am -2:00 pm ESn
HIPLEY �,,, ,,.,.,, Contact Phone #: w 8(,,,,,,66) 514-5192„ BestTimeTo Call ❑ am ❑ pm
FirsULast Contact Name: JARED S,,
Imprinter Purchase: ❑ Yes ❑ No IfYes $ 29.95 X pty: -$ (w/oTax) Wireless Provider: ❑ GPRS Cingular or ❑ Other: _,,,,,,,,,,,,,,,,,,,,,,,,, _��, �. ,,,
Check one: ❑ Gateway Solutions ❑ Dial Solutions ❑ First Data Global Gateway (FDGG) ❑ VSAT"** ❑ Frame ❑ Other:�.µ,,,�� m❑ IC Verify Serial # �,,,,,,
VAR/Internet/Softwere: Name: , INFUSION V 3.50/MONETRA (Nashville Only: Product ID # W� ,_ Vendor ID � � ..�,,e �
NOTE: `•'Requires separate agreement between VSAT Provider prior to implementation of this telecommunications protocol.
Lease Company: ❑ First Data Global Leasing (FDGL) Lease Term: months This Is a NON-CANCELABLE lease ior the fu/l term indicated.
Client
Monthl Lease Char e for This Location: Late Fees or other charges may appty - See Lease Agreement for detalls. Initials:
Y 9 5� ...............—
�`���I�M�� ��1i�i�11��� ��� ;�
DEPOSIT AUTHORIZATION
Whereas First CommunityMetchant Services, LLC and First CommunityBank (Servicers) have enterod into a
Merchant Processing Agreement (Agreement) with the undersigned Merchant (Merchant) to provide processing
Services (as that term is defined in the Agroement);
Whercas Merchant has atdhori�ed Servicers to debit via ACH transfer all fees and other amounts owing pursuant to
the Agreement from the 5ettlement Account designated in the Agreement;
Whereas, Merchant has entered into an agreement with BIS for the manag�ment of payments made to Merchant for
accounts designated to BIS by Merchant, including but not limited to the management of failed or missed paymenu
to Merchant that may occw;
Whereas, notwithstandiag the designation of the Settlement Account for the debiting of fees ac referenced above,
Merchant desires that its transection deposits pursuant to the Agreement be deposited into a bank acoount designated
by B1S;
NOW, h�REFORE, by their signatures below, Merohant and BIS agree as follows:
1. Notwithstanding anything to the conhary contained in the Agreement, effective upon the full execution
of ffiis Deposit Authorization, all �uoa�b to be paid to Merchsnt parsosat to the A�reeoeot shall be deposited
vfa ACH transfer into a"Settledeot Account^ desi=nsted by BIS. I aoder�od thst BIS Mill provide the
Settlemea�t Account dai�eatlo� to Servieera separateFy a�nd that sac6 dai�nation may aot appear on my
Merchant Processing Applica�tio�.
(a) Atl paymeots due Merchant shall be msde to th� "Settlement Account" designated by BIS unless and
until Servicen receive written nod5cation from an suthorized ropresentative of Merchent to the contrary. Servicers
are not requirod to alter their regulat coarse of biuiness with respect to aweptance of payment insUuctions from
Merchant and Servicers sbaU have no liability if they act in sccordance with payment instntetions teceived S�om aa
employee or agent of the Merchant acting with sppsrent authority. Servicers shall incur no liabilit}r for c6anges or
modifications made to the amounts fonvarded to BIS pursuant to insfructions received Erom BIS or Merchant.
Merchant and/or BIS are solely responsible for contacting the banlc roferenced in paragiaph 1 above aad notifying
them of the ACH deposits to be sent by Servicers in the oame of Metchant Servicers are not rcsponsible for any
reject of said ACfi deposits by said bank.
(b) The distribution and/or albcation of any fw�ds deposited pursuant to this Authorization is solely
betwan Merchant end BIS. Serviars shall have no respoacibility or involvement whatsoever as to how funds
deposited into thc above refercnced accouM are dispersed and/or utilized.
2. In addition to depositiag the proceeds of credit card submissions, Servicers atso utilizes the Settlement
Account W fund debits arising frnm its processing services for fas, refunds, chargebacks, and other amounts that
may be due under the A�eemen� The Merchant and BIS hereby eudiorize Serviars to access the Settkment
Account to initiate credit and/or debit e�ies by bankwire or ACH transfer to pay any amounts owing by Merchant
to Servicers pursuant to the Agreement. This authori�tion is without respect to the source of any funds in the
Settlement Account. This suthorily extends to any fees and assessmeats and chargeback artaunts of whatever kind
or nature due to Servicers under the terms of the Agreement whether arising during or aRer termination of the
Agreement.
3. Pursuant to the agreement between Merchant and BIS referenced above, Merchant understands that,
notwithstanding anything in the Agrament to the conhary, amounts chsrged may be adjusted by HIS pursuant to
MerchanYs agreement with B1S. Servicers are not rospoasible for the amow�ts charged by BIS W Merchant for its
services or for notices rolated to said charges.
4. Merchant end BIS confirm and agree that: (i) except as otherwise stated herein, the Agreement is in full
force and effect, and (u) this suthori�tion does aot prohibit, limit or elter the rights possessed by Servicers under
the Agreement in any manner whatsoever. BIS is not intended as a third paRy beneficiary of the Agreement between
Servicers and Merchant.
5.17�e Merchant and BIS agree � indemnify and hold Servicen harmless for eny action taken by Servicers
in accordance with the terms of this sutboriation.
�� N�; CITY OF FAIRFAX
I �
�BY ��� ��' �� � ��e � e� ,r,�,� ��� �F'� � � i °S� �...._ By �gjg118h1['C%
� �.w, �, •
P�at Na�ne ��'� .. .
� I��k�V9A STIMSON printName
7�' CITY CLERK/TREASURER Tide
Dated �,�'; .� -r_ "� �"�° Dsted