ATM Source of Funds Provider Declaration AgreementSource of Funds Provider Declaration Agreement • October 22nd, 2012
SECTION A – Application: ATM Source of Funds Provider Completes Lines 1-10 ** PLEASE PRINT CLEARLY** 1. Name of Location (Doing Business As) 2. Physical Street Address of Location 3. City, State, Zip 4. Location Phone Number 5. Terminal ID Number 6. Processor 7. Business Tax ID Number 8. Financial Institution Number (FI #, FDIC, NCUA, ASI) 9. Type of Business (Sole Proprietor, Partnership, LLC, Corporation, Financial Institution 10. Merchandise/Services Sold 11A. Is Source of Funds Provider an individual? If yes, complete Sections A, B and D. 11B. Is Source of Funds Provider a company? If yes, complete Sections A, C and D. SECTION B – Application: ATM Source of Funds Provider is an Individual Completes Lines 12- 23** PLEASE PRINT CLEARLY** 12. Source of Funds Provider First Name 13. Source of Funds Provider Last Name 14. Source of Funds Provider (Home) Physical Street Address 15. Source of Funds Provider (Home) City, State, Zip 16. Source of Funds Provider Social Security Number 17. So
