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CHASE 40 Merchant Services + 4 Northeastern Boulevard, Salem, NH 03079-1952 . www.chasspaymentech.com . <br />Phone: (603) 896-6000 • Fax: (603) 896-8715 • Merchant_Services@ChasePaymentech.com <br />Date: 8/5/15 <br />Addendum for Application for Credit Card Processing Service <br />Agreement/New Division Request <br />Company ID#: <br />Projected Live Date: <br />2/12/15 <br />SECTION 1: COMPANYMONTACT 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 E affiliate ❑ registered DBA or ❑ Other (explain: ) of the merchant noted above. <br />On behalf of Invoice Cloud Inc <br />(Company Legal Name) <br />l 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 />CTIQN g, BC$lN 0$$'UNl°1 (iFdlffer riffp d /stp n r ). <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 (up to 30 bytes) Business Unit M <br />$ECTN'G NDN 1 FQ'K; 11'NLif rtetrk d in e 5ectfon°;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 Paymentoch? ❑ Yes or []No <br />If yes, Bank Account # (Section 9 does not need to be completed) <br />If funds should be leposited to an existing funds transfer instruction please complete the following: <br />If USD or CAD, will this division utilize an existing Funds Transfer Instruction (FTi)?❑ Yes or ❑No lino, a now FTI will be created. <br />If yes, provide FTI # (Section 9 does not need to be completed) <br />Rev11/18/10 1 NewDivisionSetup/oboo <br />