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I nvolmceCIou 'Al <br />Invoice Parameters <br />Biller Order Form •,.,.9 <br />* Y 'E Business License ®> - 11/19/20615 <br />vaicin <br />InParameters sheet must be complete d tar each Invoke e, <br />In-house • ^' Non -Submitter <br />+ • • zVisa M MasterCard ® Discover ❑Amex ®EFT/ACH <br />.. ❑EBPP ®Cloud Store ❑ Cloud Pay ❑ OBD ❑ IVR ❑Kiosk <br />Billing Frequency: Monthly Number of Bills: 200 <br />Number of Cycles:nla <br />v Number of Installments: <br />1 <br />Average Invoice Amount: <br />$300 Highest Invoice Amount: <br />$ <br />30,000 <br />Billing Months (please select the applicable months below): <br />❑Jan ❑Feb ❑Mar ❑Apr ❑May []Jun ❑ Jul ❑ Aug ❑ Sept ❑Oct U Nov ❑ Dec ® All <br />Yf <br />❑10 -loth ❑ 1lth-20th ❑210-3T+t <br />Biller ❑ Template ❑ Bill Print Vendor (please complete below) <br />W-75 <br />e an item. QTY Choose an item. Provided by: ❑Sales Rep ❑Operations <br />Per Unit rice: $ <br />-- -- <br />Shipping Address: <br />- - - - - - (If different than locatlon address) <br />I <br />Total Due: <br />NONE$ <br />Item <br />Paid b pa er Item Paid by Biller <br />[I Credit Card: 1 i ® Credit Interchange, fees, dues assessments ents+ <br />Minimum Card: Authorization $ <br />%with Y 0.20; " . 50 ! %BP <br />❑ EFT/ACH: $ per item EFT/ACH: $ <br />0,50 per item <br />❑ Flex Pay ACH: $ per item ❑ Flex Pay ACM: $ per item <br />• <br />Item Paid b -payer Item Paid by Biller <br />❑ Credit Gard: ❑ GredIt <br />Interchange, fees, dues assessments + <br />% with Minimum Card: <br />(Without Visa Acceptance) <br />Authorization $F'+ <br />+ %BP <br />I I <br />❑ EFT/ACH: $ Per item ❑ EFT/ACH: $ Per Item <br />EICredit Card Service Fee: $ Max Cap for Credit Cards: $ <br />❑ EFT/ACH: Service Fee: $ ❑ Paid by payer ❑ 1 Paid by Biller <br />trifterocrillResIVRponse•9 <br />JI.... <br />.. ........ .. ___- _....i <br />❑ Paid by payer Service Fee + $ ❑ Paid by Biller S per item surcharge <br />9 M' Y tl Y 9 <br />Business License Cloud Store requires a custom lockbox file. City will provide the exactspeolficalons for the fil7NI <br />development is listed on page 1 ofthis BOF, <br />, <br />Requested: . Date; 12/14/2015 `'' ' ° <br />Please note the above requested date is not guaranteed. The implementotlon time frame is not guaranteed subject to change and delays to <br />workload, s stemsldata re uirements, biller coo eroNon and other factors, <br />