INVOICE CLOUD, INC. 1A -2015 - Laserfiche WebLink

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EXHIBIT C CHASE Merchant Services • 4 Northeastern Boulevard, Salem, NH 03079-1952 • www.chasepaymentech.com Phone: (603) 896-6000 • Fax: (603) 896-8715+ Merchant _ Services@ChasePayinentech.com A A Division Date: 3/31/16 CompanyID#: Projected Live Date: 711/16 SECTION 1: COMPANY/CONTACT INFORMATION Company Legal Name: Invoice Cloud, Inc Company Taxpayer ID#: 26 3972596 Contact Name: Robert Lapides Phone #: (781) 848-3733 EXT 223 Fax #: 877-256-8330 Email Address: blapides@invoicecloud.com Transactions processed for this new set up request belong to: Merchant whose company legal name is represented above... OR An Additional Company whose legal name is: City of Santa Ana and is a ❑ wholly-owned ❑ partially owned ® affiliate ❑ registered DBA or ❑ Other (explain: ) of the merchant noted above. On behalf of Invoice Cloud Inc (Company Legal Name) I, Robert Lapides EVP (Print Name) (Title) verify that the account set-up information is accurate, that I have the authority to make such a request and thus, it should be used to set up an additional account for our company. SECTION 2: BUSINESS UNIT (if different from division name) Parent Business Unit (up to 30 bytes) Parent Bus.Unit # Name (if applicable): (if applicable): Business Unit Name: City of Santa Ana (up to 30 bytes) Business Unit #: SECTION 3: FUNDING if new banking see section 9) If funds should be deposited to an existing bank account please complete the following: If USD or CAD, will funds be deposited into your existing Bank Account set up with Chase Paymentech? ❑ Yes or ❑No If yes, Bank Account # (Section 9 does not need to be completed) If funds should be deposited to an existing funds transfer instruction please complete the following: If USD or CAD, will this division utilize an existing Funds Transfer Instruction (FTI)?❑ Yes or ❑No If no, a new FT1 will be created. If yes, provide FTI # (Section 9 does not need to be completed) Rev11/18110 1 NewnivisionSetuploboo