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CHASE i0" <br />Payrnentech <br />Merchant Services • 4 Northeastern Boulevard, Salem, NH 03079.1952 • www.chasepaymentech.com <br />Phone: (603) 8968000 • Fax: (603) 898-8715 • Merchant_Services@ChasePaymentech.com <br />C1 Swift Code: (8 to 11 bytes) <br />C2 Sort Code: (Required in Great Britain Only) <br />C3 IBAN/Bank Account # <br />Company Name: (As appears on Bank account) <br />Financial Institution Name: <br />City: State/Province: <br />Special Wire Instructions: (60 bytes) <br />Postal Code: Country: <br />Sectton'D INTERMEDIARYICLEARINO BANK ACCOUNT <br />INFORMATION:. <br />Note: 'For l"n Pe '*s--bihi.,fhiouuh J.P.IG10 an:Chasean Londdii'hif2rmedI <br />la hot re ufred. Com le}e Section `C"onl <br />D1 <br />Swift Code: (8 to 11 bytes) <br />D2 Sort Code: (Required In Great Britain Only) <br />D3 Wire Transfer: (USA Only) <br />(Routing #) <br />D4 Financial Institution Name: <br />City: State/Province: Postal Code/Zip: <br />Country: <br />Special Wire Instructions: (60 bytes) <br />Sest9zin E; Si` nature `.: `` . <br />"On behalf of City of Santa Ana I, Francisco Gutierrez <br />represent and warrant <br />(Merchant Legal Name) (Print Name) <br />that I have the authority to add banking Information and I verify that the above banking information is accurate and should be used to <br />transfer funds accordingly." <br />` : �� Finance Director <br />� % i t � i o t 5 <br />Autl0rizedSignature* Title <br />Date <br />("Must be signed by Executive or Financial Contact) <br />Note. In order to process this request, please attach an original voided check (starter check or bank <br />statements not applicable) or a bank letter of verification. <br />------------------------------------------------------------------------------------------------------------------- <br />i <br />ATTACH VOIDED CHECK HERE <br />Rev11/18/10 25C-58 New Division/cboo <br />