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Home My WebLink AboutFidelity Payment Services OmahaWF22O1(ia) MERCHANT PROCESSING APPLICATION AND AGREEMENT OmahaWF2201(ia) Sales Office Fidelity Payment Services Print Sales Rep Name Josh Lieberman __- _ ___ Sales ID#0277 Merchant Number -___— Sales Rep.Signature __ Phone 5: 718-782-2823 I. BUSINESS INFORMATION Page I of6 Client's Business Name(Doing Business As): Client's Corporate/Legal Name(Use Also For Headquarter's Information): City of Auburn City of Auburn Business Address: Billing Address(If Different Than Location Address): 25 West Main Street 25 West Main Street City: State: Zip: City: State: Zip: Auburn WA 98001 Auburn WA 98001 Location Phone#: Location Fax#: Contact Name: 253-931-3033 253-876-1920 Jamie Thomas Business E-mail Address: Contact Fax#/E-mail Address: bnguyen@auburnwa.gov 253-876-1920 Business Website Address: Contact Phone 5: www.auburnwa.gov Date Business Started: Send Retrieval Requests to: ❑Business Location Corp/Legal Location 1/1/1891 Send Merchant Monthly Statement to: Business Location Corp/Legal Location Customer Service Phone#: Customer Service E-mail Address: Statement Delivery Method: 253-931-3033 bnguyen@auburnwa.gov (choose one) LI Print and Mail ❑Online via AccessOne INDIVIDUAL/SOLE PROPRIETORSHIP:State in which Certificate of Li TAX EXEMPT ORGANIZATION(501C) State: XGOVERNMENT(Federal,State,Local) Assumed Name Filed: __— __ State: IL INTERNATIONAL ORGANIZATION L LIMITED LIABILITY IT CORPORATION-CHAPTER S,C State: Location Filed: COMPANY State Filed:_ _ MEDICAL OR LEGAL CORPORATION State: Cl ASSOCIATION/ESTATE/TRUST State Filed: r_PARTNERSHIP State Filed: Name(as it appears on your income tax return) FEDERAL TAX ID# ❑ I certify that I am a foreign entity/nonresident alien. (as it appears on your income tax return) (If checked,please attach IRS Form W-8.) City of Auburn 916001228 NOTE:Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations.(See Part IV,Section A.4 of your Program Guide for further information.) `SIC/MCC:9399 Final Auth.Indicator: ❑ 0(Pre Auth.) ❑ 1 (Final Auth.) IATA/ARC: (MCC 4722 Only) Note:*11 your business is classified as High Risk and assigned(or is later assigned based upon your business activity)any of the following Merchant Category Codes(MCC):5966,5967 and 78411, then registration is required with Visa and/or MasterCard within 30 days from when your account becomes active.An Annual Registration Fee of$500 may apply for Visa and/or MasterCard(total registration fees could be 51,000.00).Failure to register could result in fines in excess of S10,000.00 for violating Visa and/or MasterCard regulations2. 1Registration for MCC 7841 is only required for non-face-to-face adult content. 2lnformation herein,including applicable MCCs,is subject to change. Detailed Explanation of Type of Merchandise,Products or Services Sold: City Gov-Building Permits 2. ADDITIONAL CREDIT / SITE SURVEY INFORMATION - ALL MERCHANTS 1. Zone: (Business District ❑Industrial ❑Residential 13. Do you have a refund policy for MC/Visa/ Discover'Network-PayPal/American Express OptBlue'Sales? 2. Location: L.Mall XOffice ❑Home Shopping Area ❑Yes ❑No If yes,check one: 12 Apartment 7 Isolated -Door-to-Door Li Exchange ❑MC/Visa/Discover Network-PayPal/ Flea Market Li Other ❑Store Credit American Express OptBlue'Credit If MC/V/Discover Network-PayPal/American Express OptBlue'Credit,within how many 3. How many employees: days do you submit credit transactions? 4. How many registers/Terminals: ❑0-3 7 4-7 7 8-14 7 Over 14 5. Is proper license visible? 7 Yes 14. Advertising Method(Attach at least one): ❑Catalog ❑Brochure ❑Direct Mail ❑TV/Radio ❑No,explain: — ❑Internet ❑Phone ❑Newspaper/Journals ❑Other 6. Where is the merchant name displayed at the site? Marketing Materials required for Mail Order,B to B, Internet over S1 Million in annual volume.Attach Web Page for Internet Merchant. ❑Window L.Door $`i Store Front 15. Previous Processor: 7. Merchant Occupies: X Ground Floor ❑Other: 16. Check Reason For Leaving:❑Rate ❑Service ❑Terminated ❑Other: 8. #of Floors/Levels: L 1 X2-4 L 5-10 ❑11+ 9. Remaining Floor(s)Occupied by: Mail/Telephone Order/Business to Business/Internet Information (All Questions must be Answered) Li Residential C::Commercial Li Combination XNone 1. What is the time frame from transaction to delivery?(%of orders delivered in): 10. Approximate Square Footage: 0-7 days 100%+8-14 days 0_%+15-30 days_ %+over 30 days Q.%=100% 0 0-250 ❑251-500 ❑501-2,000 ❑2,001 plus 2. MC/Visa/Discover Network-PayPal/American Express OptBlue'sales are deposited(check one): 11. Are customers required to leave a deposit? El Date of order XDate of delivery ❑Other(specify): No -Yes If Yes,%of deposit required: % 3. Does any of your cardholder billing involve automatic renewals or 12. Return Policy: ❑Full Refund =Exchange Only ❑None recurring transactions(i.e.,cardholder authorizes initial sale only)? ❑Yes E.No Merchant Initials: DBA Name: City of Auburn Merchant#: Page 2 of 6 OmahaWF2201(ia) I 3. OWNERS / PARTNERS / OFFICERS I OmahaWF2201(ia) Provide the following information for each individual who owns,directly or indirectly,25%or more of the equity interest of your business. OWNER/PARTNER/OFFICER 1 Name:(First,Ml,Last) %Ownership: Title: Jamie Thomas 0 Director Home Address:(No P.O.Box) City: State: Zip: Country: 25 West Main Street Auburn WA 198001 Telephone#: Social Security#: D.O.B.: DL#: State: 253-931-3033 116-01-2689 01/01/1991 OWNER/PARTNER/OFFICER 2 OWNER/PARTNER/OFFICER 3 Name:(First,MI,Last) %Ownership: Name:(First,MI,Last) %Ownership: 0 Title: Telephone#: Title: Telephone#: Home Address:(No P.O.Box) Home Address:(No P.O.Box) City: State: Zip: Country: City: State: Zip: Country: D.O.B.: Social Security#: D.O.B.: Social Security#: OWNER/PARTNER/OFFICER 4 OWNER/PARTNER/OFFICER 5 Name:(First,Ml,Last) %Ownership: Name:(First,Ml.Last) /Ownership: Title: Telephone#: Title: Telephone#: Home Address:(No PO.Box) Home Address:(No PO.Box) City: State: Zip: Country: City: State: Zip: Country: D.O.B.: Social Security#: D.O.B.: Social Security#: 4. SETTLEMENT INFORMATION Deposit Bank: Key Bank Transit/ABA#: 125000574 Deposit Account#: 471431003238 ACH Detail Flag: ❑Individual X Combined ❑Separate (defaults to Combined if option not selected) S. TRANSACTION INFORMATION FINANCIAL DATA WHERE IS SALE Gross YEARLY Sales Volume Avg.MC/Visa/Discover Network- TRANSACTED? (Cash+Credit+Debit+Check) $ 700000 PayPal Ticket(Estimate If Never Processed in Past) $ 150 (must=100%) Avg.American Express Store Front/Swiped 0 Average YEARLY MC/Visa Volume $ 600000 OptBlueTicket(Estimate If Never Processed in Past) $ Average YEARLY Discover Network- Internet 0 PayPal Volume $ 60000 Highest Ticket Amount $ 700 Mail Order Average YEARLY American Express OptBlue°'Volume $ 0 Telephone Order 100 Seasonal?X No❑Yes High Volume Months Open: Total 100% 6. GRID INFORMATION — INTERNAL USE ONLY AUTHORIZATION GRID ID#: USER DEFINED GRID ID#: MFC GRID ID: 8-pos.Alpha/Numeric MC TIERED VISA TIERED DISCOVER NETWORK-PayPal GRID ID 8-pos.Alpha/Numeric GRID ID 8-pos.Alpha/Numeric TIERED GRID ID 8•pos.Alpha/Numeric AMERICAN EXPRESS OptBlue"TIERED 8-pos.Alpha/Numeric GRID ID MC CREDIT VISA CREDIT _ DISCOVER NETWORK-PayPal MPG ID 8-pos.Alpha/Numeric MPG ID 8-pos.Alpha/Numeric CREDIT MPG ID 8-pos.Alpha/Numeric AMERICAN EXPRESS BIT VISA DEBIT DISCOVER NETWORK OptBlue`CREDIT 8-pos.Alpha/Numeric MC DEMPG ID 8-pos.Alpha/Numeric MPG ID 8-pos.Alpha/Numeric DEBIT MPG ID 8-pos.Alpha/Numeric MPG ID 7. SERVICE FEE SCHEDULE Accept all MasterCard,Visa,Discover Network and American Express OptBlue`Transactions(presumed,unless any selections below are checked) MasterCard Visa Discover Network American Express OptBlue' r-MC Credit Transactions ❑Visa Credit Transactions LI Discover Network Credit Transactions ❑American Express Credit Transactions MC Non-PIN Debit Trans. ❑Visa Non-PIN Debit Trans. C Discover Network Non-PIN Debit Trans. Discover Network-PavPal X Discount Collected ❑Daily Monthly __Discover Network-PayPal Credit Transactions Merchant Initials: DBA Name: City of Auburn Merchant#: _ Page 3 of 6 OmahaWF2201(ia) 7. SERVICE FEE SCHEDULE (coned) OmahaWF2201(ia) Tiered Discount Fees(Based on Gross Sales Volume) Discount MPG TXN Fee Discount MPG TXN Fee Discount MPG TXN Fee - Discount MPG TXN Fee MC Visa Discover Network- American Express Dual Credit % $ Qual Credit % $ PayPal Dual Credit % $ OptBlue'Qual Credit % $ MC Visa Discover Network- American Express Mid-Dual Credit % $ Mid-Dual Credit % $ PayPal Mid-Dual Credit % $ OptBlue'Mid-Dual Credit % $ MC Visa Discover Network- American Express Non-Dual Credit % $ Non-Dual Credit % $ PayPal Non-Dual Credit % $ OptBlue'Non-Dual Credit % $ MC Worldcard Dual % $ Visa Rewards 1 % $ MCWorldcard % $ Visa Rewards 2 % $ MCCMid-DualWorldcard Non-Dual % $ —_ MC Visa Discover Network Dual Debit % $ Dual Debit % $ Dual Debit % $ MC Visa Discover Network Mid-Dual Debit % $ Mid-Dual Debit % $ Mid-Dual Debit % $ MC Visa Discover Network $ Non-Dual Debit % $ Non-Dual Debit % $ Non-Dual Debit MC Regulated Visa Regulated Discover Network Debit Discount % $ Debit Discount % $ Regulated Debit Disc't % $ ERR Discount Non-Qual Fees Discount Non-Dual Fees Discount Non-Dual Fees - _ Discount Non-Dual Fees Discover Network- American Express MC Qual Credit 0 % % Visa Dual Credit 0% % PayPal Qual Credit 0% % OptBlue'Dual Credit 0 Discover Network 0 MC Dual Debit 0 % % Visa Dual Debit 0% % Qual Debit Pass Through Interchange 0 Net Only-Includes Dues and Assessments Gross Only-Includes Dues and Assessments Discount(Based Discount(Based , Discount(Based Discount(Based ) on Gross Sales n Gross Sales Vol.) on Gross Sales Vol. on Gross Sales Vol.) Vol)1 MC Dual Credit % Visa Qual Credit % Discover Network-PayPal Dual Credit % American Express OptBlue'Dual Credit % American Express OptBlue"has Program Pricing and not MC Dual Debit % Visa Dual Debit % Discover Network Dual Debit % Interchange and are subject to change. Other Item Rate Discover Network- American Express MC Credit $ Visa Credit $ PayPal Credit $ OptBlue Credit $ Discover Network MC Debit $ Visa Debit $ Debit $ Other Volume% Discover Network- American Express MC Credit Visa Credit % PayPal Credit % OptBlue"Credit % _._■ Discover Network MC Debit % Visa Debit % Debit % PIN Debit Pass Through Debit Network Fees Other Item Rate $ (per item) Other Volume Percent %(per item) Fleet WEX: Other Item Rate $ (per item) Voyager: Qual % Other Item Rate $ (per item) TeleCheck _'In-Person Warranty C Mail Order Warranty C Single Hold Check Warranty ❑Multiple Hold Check Warranty L In-Person Paper Warranty ❑C.O.D.Warranty SE# Inquiry Rate % Per TXN Fee $ Stmt/Processing Fee $ 5.00 Dec.Risk Surcharge .10 Monthly Minimum Fee $ (Per Location) Customer Requested Operator Call(GROG) $ 2.50 Unauthorized Return Fee S 5.00 Miscellaneous Fees Dues and Assessments V/MC Chargeback V/MC Retrieval Return Trans. Fee (Per Item)$ 0 Fee(12B Letter) (Per Item)$ 0 Fee (Per Item)$ Sales Transaction Early Termination Fee (Per Item)$ Batch Fee (Per Item)S Fee (One Time Fee)$ eIDS Access Fee(Flat Rate)$ EBT— EBT— Other: Food Stamps (Per Item)$ #: Cash Benefits (Per Item)$ $ Monthly Statement Fee Pass Visa Minimum Monthly Fee $_ (Acct on File) 0 $ 0 ACH Reject Fee (Per Item)$ 0 Trans Integrity Fee C Yes X No Monthly MC License Fee % (Flat Rate)$ :7,Annually in December (Per Sales Item) $ (Sales Volume) Visa Proc Fee (Per Item)$ MC Proc Fee (Per Item)$ Visa BIN Fee (Per Item)$ MC ICA Fee (Per Item)$ Pass Visa Fixed Acquirer Network Fee(FANF) ❑Yes X No Visa FANF Card Present Surcharge (Flat Rate)S Visa FANF Card Not Present Surcharge (Flat Rate)S Pass Visa Pass Visa Pass Visa Pass Visa Acquirer Processing Fee ❑Yes X No Misuse of Auth Fee C Yes X No Zero Floor Limit Fee C Yes X No Intl Acquirer Fee C Yes X No Pass MC Pass MC Pass Discover Pass Visa Acquirer Support Fee C Yes X No Cross Border Fee Yes X No Data Usage Charge C Yes X No Acq ISA Fee C Yes Xr No Pass Discover Intl Processing Fee C;Yes X No Pass Discover Intl Service Fee i_1 Yes X No Pass MC Nat'l Acquirer Brand Usage(NABU)Fee LI Yes X No Merchant Initials: A DBA Name: City of Auburn Merchant#: Page 4 of 6 OmahaWF2201(ia) 7. SERVICE FEE SCHEDULE (coned) OmahaWF2201(ia) Authorization & Capture Transaction Fees First Data Payeezy"Gateway Services MC/Visa Auth&Capture Fee: $ (per item) —'Payeezy Gateway Participation Discover Network PayPal Auth&Capture Fee: $ Payeezy Gateway Effective Date:_ (per item) Payeezy Gateway One Time Setup Fee $ one time) American Express OptBlue"Auth&Capture Fee: $ (per item) ( Payeezy Gateway Monthly Fee $ (monthly) American Express Pass Through(existing)SE#: Payeezy Gateway Auth Fee $ (per item) Voice Authorization $ (per item) Payeezy Gateway AVS Fee Electronic AVS Fee $ (per item) $ (per item) Payeezy PayPal Auth Fee $ (per item) Voice AVS Fee $ (per item) Payeezy PayPal Sale Fee $ (per item) ARU Fee $ (per item) Payeezy PayPal Return Fee $ _(per item) First Data Payeezy"Gateway Services Telecheck Payeezy Gateway Payeezy Gateway Payeezy Gateway TeleCheck Auth Fee $ (per item) TeleCheck Deposit Fee $ (per item) TeleCheck Adjustment Fee $ (per item) User Defined Grid Fees TIN/TFN& Regulatory Product Fees Wireless Monthly Service Fee $ AccessOne Fee $ Reg.Product Fee (Monthly)$ Customer Service Fee $ Debit Access Fee $ TIN/TFN Invalid (Monthly)$ Supplies: $ Other: $ Website Usage (Per Item)$ Merchant Fee Control Grid Fees Annual Fee $ Other: $ Other: $ Month ❑Per item ❑Monthly ❑Annually Month ❑Per item ❑Monthly ❑Annually Month Pass Visa Account Verification Fee ❑Yes X No Visa Account Verification Fee Surcharge (Per Item)$ Pass VISA BIN/ICA Fee (Note:this fee can only be used for Shared Systems Only) G Yes X No VISA BIN/ICA Fee Surcharge (Per Item)$ Pass Visa Staged Digital Wallet Fee E Yes X No Visa Staged Digital Wallet Fee Surcharge (Per Item)$ Pass Visa B2B Virtual Payments Fee 10 Yes X No Visa B2B Virtual Payments Fee Surcharge (Sales Volume) Pass Visa File Transmission Fee 7 Yes X No Visa File Transmission Transaction Fee Surcharge (Per Item)$ Pass Visa Acquirer Credit Voucher Data Processing Fee C Yes X No Visa Acquirer Credit Voucher Data Processing Fee Surcharge (Per Item)$ Pass Visa AFD Non Participation Fee ❑Yes X No Visa AFD Non Participation Fee Surcharge (Per Item)$ Pass Discover Card Account Verification Fee ❑Yes X No Discover Card Account Verification Fee Surcharge (Per Item)$ Pass Discover Network Auth Fee ❑Yes X No Discover Network Auth Fee Surcharge (Flat Rate)$ or (Per Item)$ Discover Dispute Fee (Per Item)$ Discover Retrieval Fee (Per Item)$ Pass PayPal Participation Authorization Fee _Yes X No PayPal Participation Authorization Fee Surcharge 9 (Sales Volume) Pass American Express OptBlue Access Fee L Yes X No Pass American Express OptBlue'Network Fee 1_G Yes X No American Express OptBlue'Network Fee Surcharge 9 (Sales Volume) American Express Dispute Fee (Per Item)$ American Express Retrieval Fee (Per Item)$ Pass MasterCard Processing Integrity Fee Pre Auth 7 Yes X No MasterCard Processing Integrity Fee Pre Auth Surcharge (Per Item)$ Pass MasterCard Processing Integrity Fee Undefined Auth E Yes X No MasterCard Processing Integrity Fee Undefined Auth Surcharge (Per Item)$_ Pass MasterCard Processing Integrity Fee Final Auth% C Yes X No Pass MasterCard Processing Integrity Fee Final Auth Minimum Per Item LI Yes ❑No Pass MasterCard Processing Integrity Invalid Acquirer MasterCard Processing Integrity Invalid Acquirer Authorization ICA Fee 0 Yes X No Authorization ICA Fee Surcharge (Per Item)$ Pass MasterCard Processing Integrity Message MasterCard Processing Integrity Message Format Error Fee G Yes X No Format Error Fee Surcharge (Per Item)$ Pass MasterCard Processing Integrity Image Fee C Yes X No MasterCard Processing Integrity Image Fee Surcharge (Per Item)$ Pass MasterCard BIN/ICA Fee (Note:this fee can only be used for Shared Systems Only) L Yes X No MasterCard BIN/ICA Fee Surcharge (Per Item)$_ Pass MasterCard Account Status Fee i.:Yes X No MasterCard Account Status Fee Surcharge (Per Item)$ Pass MasterCard Kilobyte Fee E Yes X No MasterCard Kilobyte Fee Surcharge (Flat Rate )$ or (Per Item)$ Pass MasterCard CVC2 Fee7 Yes X No MasterCard CVC2 Fee Surcharge (Flat Rate)$ or (Per Item)$ Pass MasterCard ICA AVS Fee C Yes X No MasterCard ICA AVS Fee Surcharge (Per Item)$ Pass MasterCard Digital Enablement Fee ❑Yes X No MasterCard Digital Enablement Fee Surcharge 9 (Sales Volume) Pass MasterCard Business to Business US 0 Yes X No MasterCard Business to Business US Surcharge 9 (Sales Volume) % Pass MasterCard SecureCode Transaction Fee E Yes X No MasterCard SecureCode Transaction Fee Surcharge g (Flat Rate)$ Merchant Initials: DBA Name:City of Auburn Merchant 1f: Page 5 of 6 OmahaWF2201(ia) 7. SERVICE FEE SCHEDULE (cont'd) I OmahaWF2201(ia) Pass MasterCard Location Fee LI Yes X No MasterCard Location Fee Surcharge (Flat Rate)$ Pass Retrieval Received Fax/Mail Fee El Yes X. No Retrieval Received Fax/Mail Fee Surcharge (Per Item)$_ Pass Chargeback Received Fax/Mail Fee ❑Yes X. No Chargeback Received Fax/Mail Fee Surcharge (Per Item)$ Pass Retrieval Outgoing Fax/Mail Fee ❑Yes X No Retrieval Outgoing Fax/Mail Fee Surcharge (Per Item)$ Pass Chargeback Outgoing Fax/Mail Fee ❑Yes X No Chargeback Outgoing Fax/Mail Fee Surcharge (Per Item)$ Pass Visa Accept/No Accept Fee ❑Yes X No Visa Accept/No Accept Fee Surcharge (Per Item)$ Pass MasterCard Accept/No Accept Fee ❑Yes$)No MasterCard Accept/No Accept Fee Surcharge (Per Item)$ Pass Discover Accept/No Accept Fee ❑Yes g No Discover Accept/No Accept Fee Surcharge (Per Item)$ Pass American Express Accept/No Accept Fee ❑Yes X No American Express Accept/No Accept Fee Surcharge (Per Item)$ Pass Visa Late Response to Dispute Fee ❑Yes)t No Visa Late Response to Dispute Fee Surcharge (Per Item)$ Pass MasterCard Late Response to Dispute Fee ❑Yes X No MasterCard Late Response to Dispute Fee Surcharge (Per Item)$ Pass Discover Late Response to Dispute Fee El Yes)<No Discover Late Response to Dispute Fee Surcharge (Per Item)$ Pass American Express Late Response to Dispute Fee ❑Yes X No American Express Late Response to Dispute Fee Surcharge (Per Item)$ Pass STAR Debit Network Annual Fee ❑Yes X No STAR Debit Network Annual Fee Surcharge (Flat Rate)$ Pass STAR Access Dispute Fee (Per Item)$ Pass STAR Access Retrieval Fee (Per Item)$ Pass Pulse Debit Network Annual Fee ❑Yes X No Pulse Debit Network Annual Fee Surcharge (Flat Rate)$ Pass Jeanie Debit Network Annual Fee ❑Yes X No Jeanie Debit Network Annual Fee Surcharge (Flat Rate)$ Pass NYCE Debit Network Annual Fee ❑Yes X No NYCE Debit Network Annual Fee Surcharge (Flat Rate)$ Pass Accel Debit Network Annual Fee ❑Yes X'i No Accel Debit Network Annual Fee Surcharge (Flat Rate)$ Pass NACHA Unauthorized Entry Fee (Per Item)$_ 4.50 NACHA Unauthorized Entry Fee Surcharge (Per Item)$ Commercial Card Interchange Service ❑Yes CI No With the Commercial Card Interchange Service.when transactions do not include any tax information we will compute the sales tax based on the applicable rate at your location to allow you to obtain the best interchange.When we compute the sales tax on your behalf.we will retain 50%of the interchange savings.If a transaction is fully or partially exempt,you should enter the tax amount(even if that amount is$0.00)as CCIS applies your local tax rate to the full amount of transactions when the prompt is bypassed. TransArmor Data Protection Fee (Flat Rate)$_ TransArmor Terminal Fee (Flat Rate)$ Pass PCI Non Compliance Fee(Monthly) (Flat Rate)$ PCI Rapid Comply (Flat Rate)$ Clover Security Plus Fee (Flat Rate)$ Clover Security for Clover Fee (Flat Rate)$ Clover Security Non Clover Fee (Flat Rate)$ Clover Service Fee Monthly(per station) (Flat Rate)$ Clover Security Plus w/o TransArmor Data Protection (Flat Rate)$ Clover Insights Fee(per MID) (Flat Rate)$ Wireless Monthly Service Fee (Per Item)$ Wireless Activation Fee (Flat Rate)$ Clover Go Monthly Fee(per MID) (Flat Rate)$ DCC Chargeback Fee Per Chargeback$ DCC Retrieval Fee Per Retrieval$ DCC Transaction Fee Per Settlement$_ 8. EQUIPMENT/THIRD PARTY INFORMATION Network(Front End): El Omaha ❑North Nashville ❑Buypass Do you use any third party to store,process or transmit cardholder data? LI Yes ❑No If yes,identify the Third Party Processor used: ❑00 None J 01 Yahoo 02 Authorize.net El 03 Cybersource 04 Verifone Li 05 Merchant Link ❑06 Shift 4 C 08 FIS L 09 Six Payment Services Corp ❑10 Verisign ❑99 Other(please specify) INTERNET GATEWAY: LI First Data Global Gateway C:Other: Wireless Network: PC/Internet Software Quantity ❑New ❑Rent ❑Lease ❑Existing Terminal Model Quantity 0 New Rent ❑Lease ❑Existing Printer Model Quantity _ ❑New C Rent ❑Lease ❑Existing PIN Pad — Quantity C New ❑Rent ❑Lease ❑Existing Merchant Initials: DBA Name: City of Auburn Merchant t: Page 6 of 6 OmahaWF2201(ia) 1 B. EQUIPMENT/THIRD PARTY INFORMATION (coned) 1 OmahaWF2201(ia) LEASE COMPANY: (04)First Data Global Leasing Annual Tax Handling Fee: 0 AL,AR,CA,CT,GA,IN,KY,LA,MS,MO,NE,NY,NM, El All other Lease Term: Mos. NC,OK,OR,RI,SC,TN,TX,VT,VA,WA,WV,WI,WY 30.20 States 10.20 Total Monthly Lease Charge: $ Total Cost To Lease(without tax): $ (w/o taxes,late fees,or other charges that may apply-See Lease Agreement in Program Guide for details.This is a non-cancelable lease for the full term Indicated.) Option to purchase: If you wish to buyout the equipment, please contact 1-877-257-2094 to obtain the cost. Address 1City I State Zip (Attention: U. SIGNATURE(S) Client certifies that all information set forth in this completed Merchant Processing Application is true and correct and that Client has received a copy of the Program Guide and Confirmation Page,which is part of this Merchant Processing Application(consisting of Sections 1-9),and by this reference incorporated herein.Client acknowledges and agrees that we,our Affiliates and our third party subcontractors and/or agents may use automatic telephone dialing systems to contact Client at the telephone number(s)Client has provided in this Merchant Processing Application and/or may leave a detailed voice message in the event that Client Is unable to be reached,even If the number provided is a cellular or wireless number or If Client has previously registered on a Do Not Call list or requested not to be contacted Client for solicitation purposes.Client hereby consents to receiving commercial electronic mail messages from us,our Affiliates and our third party subcontractors and/or agents from time to time.Client further agrees that Client will not accept more than 20'/.of its card transactions via mail,telephone or Internet order.However,if your Application is approved based upon contrary information stated in Section 5,Transaction Information section above,you are authorized to accept transactions in accordance with the percentages indicated in that section.This signature page also serves as a signature page to the Equipment Lease Agreement,and the TeleCheck Solutions Agreement appearing in the Third Party Section of the Program Guide,if selected,the undersigned Client being the"Lessee"for purposes of such Equipment Lease Agreement and/or"You"and"Your" for the purposes of the TeleCheck Solutions Agreement. By signing below,each of the undersigned authorizes us,our Affiliates and our third party subcontractors and/or agents to verity the information contained in this Application and to request and obtain from any consumer reporting agency and other sources,including bank references,personal and business consumer reports and other information and to disclose such information amongst each other for any purpose permitted by law.If the Application is approved,each of the undersigned also authorizes us,our Affiliates and our third party subcontractors and/or agents to obtain subsequent consumer reports and other information from other sources,including bank references,in connection with the review,maintenance,updating,renewal or extension of the Agreement or for any other purpose permitted by law and disclose such information amongst each other.Each of the undersigned furthermore agrees that all references,including banks and consumer reporting agencies,may release any and all personal and business credit financial Information to us,our Affiliates and our third party subcontractors and/or agents.Each of the undersigned authorizes us,our Affiliates and our third party subcontractors and/or agents to provide amongst each other the information contained In this Merchant Processing Application and Agreement and any information received subsequent thereto from all references,including banks and consumer reporting agencies for any purpose permitted by law.It is our policy to obtain certain information in order to verify your identity while processing your account application. As part of our approval,processing services,continuing fraud prevention and account review processes,the undersigned consents to the use of information gathered online or that you submit to us,and/or automated electronic computer security screening,by us or our third party vendors. Client authorizes FRMS and Bank and their affiliates to debit Client's designated bank account via Automated Clearing House(ACE)for costs associated with equipment hardware,software and shipping. You further acknowledge and agree that you will not use your merchant account and/or the Services for illegal transactions,for example,those prohibited by the Unlawful Internet Gambling Enforcement Act, 31 U.S.C.Section 5361 et seq, as may be amended from time to time,or processing and acceptance of transactions in certain jurisdictions pursuant to 31 CFR Part 500 et seq.and other laws enforced by the Office of Foreign Assets Control(OFAC). Client certifies,under penalties of perjury,that the federal taxpayer identification number and corresponding filing norm provided herein are correct. Client agrees to all the terms of this Merchant Processing Application and Agreement.This Merchant Processing Application and Agreement shall not take effect until Client has been approved and this Agreement has been accepted by FRMS and Bank. Client's Business Principal/ can (Servicersp For First Data Merchant Services LLC j J� and Miens Fargo Bank,N.A., Signature X 41, (f' ! Title Finan a Director (a member of visa USA.Inc. j ., nand MasterCard International,Inc.) 1111 Print Name o gree Jamie Thomas pater X tggnattere "USE LIMITED TO CONTRACT ACCEPTANCE" Signature X Title Print Name of Signer Date Signature X Title Print Name of Signer Date �` ---- TELECHECK ACM AUTHORIZATION ACH Debit and Credit Authorisation:Client - its Financial Institution to pay and charge to its accoun . - •• s due TeleCheck under this TeleCheck Agreement and to accept all credits and debits made to its acc - heck via electronic hi • - - connection with TeleCheck's services under this TeteCheck Agreement.This authorization shall remain in effect until(30)thirty days after r- r.,•__ •.''r0 m. Signature X � Print Name/Title: Date �,__ -•- — uSignature on TeleCheck Account for ACH PersonarGua tee: In exchange for First Data Merchant Services LLC,Wells Fargo Bank,N.A.,(a member of Visa USA,Inc.and MasterCard Interngtiona no.),and TeleCheek Services, . Guaranteed Parties)acceptance of,as applicable,the Agreement,and/or the Equipment Lease Agreeme__n.. e TeleCheck/TRS Solutions Agreement, the under nconditionally and irrevocably guarantees the full payment and performance of C t'ligations under the foregoing agreements,as applicable,as they now exist •. filed from time to time,whether before or after termination or pit of such agreements and whether or not the undersigned has received notice of any amendment of suc .. ants.The undersigned waives notice o f y Client and agrees to indemnify the Guaranteed Parties for any and all amounts due from Client under the foregoing agreemen GuaranteedP shat not be required to first proceed against Client to enforce any remedy before proceeding against the undersigned.This is a continuing personal guarartr.•. ail not be discharged or affected for any reason.The undersigned understands that this is a Personal Guaranty of payment and not of collection an. •• e Guaranteed e relying upon this Personal Guaranty in entering into the foregoing agreements,as applicable. Personal Guarantee Sign e—X Print Name: Date Pers a Guarantee Signature X Print Name: Date