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CHASEC iM <br />Merchant Services + 4 Northeastern Boulevard, Salem, NH 03079-1952 • www.chasepaymentech.com <br />'Paynien.ech Phone: (603) 896.6000 • Fax: (603) 896-8715 + Merchant_Servlces@ChasePaymentech.cam <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 />Section D INTERMEDIARY7CLEARING BANK ACCOUNT INFORMATION <br />Moto: Pow In 'i a osits, goinli throtr h J,P. Mor en chase in London, termediary Is not required, Complete 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 />Section E;Ignatutre <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 />n T-.. �.P� �-- - � <br />„ 12 1 1�- <br />. <br />Authorized Signature* 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 />ATTACH VOIDED CHECK HERE <br />Rev11/18/10 9 New Divislon/cboo <br />