AUTOMATED CLEARING HOUSE PROCESSING AGREEMENTAutomated Clearing House Processing Agreement • October 17th, 2019 • Arizona
Reseller’s Name: CHECK COMMERCE USE ONLY BELOW: Merchant ID: Entered By: Date: I. MERCHANT INFORMATION: Federal Tax ID Number: State Tax ID Number: Business Name: DBA: Address: City: State: Zip Code: Telephone Number: Fax Number: Primary Email: Website Address: II. PRINCIPAL / INDIVIDUAL 1 Name: Title: % of Ownership: Driver’s License #: State: Address: City: State: Zip Code: Residence Phone: Social Security Number: Date of Birth: II. PRINCIPAL / INDIVIDUAL 2 Name: Title: % of Ownership: Driver’s License #: State: Address: City: State: Zip Code: Residence Phone: Social Security Number: Date of Birth: III. FEES Per Transaction / Per Settlement: Per Return / Per Exception: Discount Rate: Authentication Fee: Monthly Maintenance Fee: Per Chargeback: Application Fee: Collections Service Fee: Quarterly Compliance Fee:$24.95 Early Termination Fee:$500.00 Proof of Authorization (POA) Fee:$10.00 Other: IV. RETURN THRESHOLDS [CHECK COMMERCE USE ONLY]
