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CHASE C Merchant Services • 4 Northeastern Boulevard, Salem, NH 03079-1952 • www.chasepaymentech.com <br />Phone: (603) 896-6000 • Fax: (603) 896.8715 • Morchant—Servlces@ChasePayrnentech.com <br />Pay"me-S"9t�?er h <br />Addendum for Application for Credit Card Processing Service <br />Agreement/New Division Request <br />Date: 8/5/15 Company ID#: <br />Projected Live Date: 12/14/15 <br />SECTION 1; COMPANY/CONTACT INFORMATION. <br />Company Legal Name: Invoice Cloud, Inc <br />Company Taxpayer ID#: 26 3972596 <br />Contact Name: Robert Lapides Phone #: (781) 848-3733 EXT 223 <br />Fax #: 877-256-8330 Email Address: blapides@invoicecloud.com <br />Transactions processed for this new set up request belong to: <br />Merchant whose company legal name is represented above... <br />OR <br />An Additional Company whose legal name is: City of Santa Ana and is a ❑ wholly-owned <br />❑ partially owned ® affiliate ❑ registered DBA or ❑ Other (explain: ) of the merchant noted above. <br />On behalf of Invoice Cloud Inc <br />(Company Legal Name) <br />1, Robert Lapides EVP <br />(Print Name) (Title) <br />.verify that the account set-up information is accurate, that I have the authority to make such a request and <br />thus, it should be used to set up an additional account for our company. <br />'SECT{O;N �; B.I.ISINESS UNIT ifdlf#er`eriC#oirl�ttviston nam '- <br />Parent Business Unit (up to 30 bytes) Parent Bus.Unit # <br />Name (if applicable): (if applicable): <br />Business Unit Name: City of Santa Ana NP to 30 bytes) Business Unit #: <br />SECTft7N���'�1I1l7fNG, t`ne�+bdttk/ `ss�sec¢%n=,9 <br />If funds should be deposited to an existing bank account please complete the following: <br />If USD or CAD, will funds be deposited into your existing Bank Account set up with Chase Paymentech? ❑ Yes or ❑No <br />If yes, Bank Account # (Section 9 does not need to be completed) <br />If funds should be deposited to an existin sfe <br />funds tranr Instruction please complete the followin <br />If USD or CAD, will this division utilize an existing Funds Transfer Instruction (FTI)?❑ Yes or []No trno, a new FTI will be created. <br />If yes, provide FTI # (Section 9 does not need to be completed) <br />Revt t/18/10 25C-40 NewDivisionSetup/cboo <br />