GPPS Diverse

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Attached you will find your enrollment package. Please use this cover page as a check list and fax cover sheet to submit the appropriate documentation to our DiversePayments processing department.

Check When Completed Application package items Please complete each item in full

Merchant Application - Page 2 Describes your company, history, business details, and contact information.

Merchant Agreement - Page 3,4,5 This agreement governs how DiversePayments does business with your company.

Corporate Resolution - Page 6 Complete form if your business is a corporation and there is not the majority (50+%) owner.

Additional Locations - Page 7 Team members who are actively selling your product or working with your customers to determine financing options.

Team Member Roster - Page 8 Team members who are actively selling your product or working with your customers to determine financing options.

ACH & Voided Check - Page 9

Authorizes us to access your designated account to debit monthly membership fees and credit the merchant payout portion of the funded loans.

Check When Completed Required items to complete All licenses and legal documents must be current and in good standing

Business License Document that shows you are legally able to do business at your business address.

Professional License(s)

Document that shows you are legally permitted to perform consumer goods and/or services. Examples: Contractor License, Plumber License, HVAC License. Training Centers must be certified by their respective board.

Legal Entity Filing

Document with your company’s legal name/shows that DBA has been filed with a government agency. Examples: IRS Forms such as Schedule C, C-EZ, F, Tax Returns, Articles of Incorporation, State/County/City tax permit/document.

NOTE: If you are unable to provide any of the documents above, please explain your reason(s) in a separate document. Certain lender partners may require 2 years of financial statements and/or bank statements.

IMPORTANT: If you have been in business for less than 1 year, you need to include the following in your application packet:

1. Lease/Mortgage Agreement: Please include the page with the physical address and the complete lease terms 2. Sales statements from 2 vendors: Must have vendor contact information

Once the following items above are complete, please print, sign, and

Scan and e‐mail to [email protected]

DiversePayments will begin its due diligence process upon receipt of a complete package!

For questions, please call our Financing Specialists

(855) 800‐2580

Tel 855.800.2580 Fax 855-580-2580 [email protected]

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MERCHANT APPLICATION

23175 La Cadena Drive., Suite B Laguna Hills, CA 92653

Tel: 855-800-2580 Fax: 855-580-2580 Email: [email protected]

SECTION #1 MERCHANT INFORMATION FULL LEGAL NAME OF BUSINESS DBA NAME

LEGAL ADDRESS / STREET PHYSICAL ADDRESS / STREET (if different from legal address):

CITY STATE ZIP CITY STATE ZIP

OFFICE PHONE FAX WEBSITE URL

PRIMARY LOAN ADMINISTRATOR NAME EMAIL

SECTION #2 BUSINESS PROFILE

TYPE OF OWNERSHIP

CORPORATION

SUB S CORP

LLC

SOLE PROPRIETOR

PARTNERSHIP

TYPE OF BUSINESS PRODUCTS /SERVICES FINANCED

Do you currently offer a financing program to your clients/customers? If yes, through who?

PRODUCT/SERVICE DELIVERY TIME TOTAL ANNUAL SALES VOLUME ($) AVERAGE CONTRACT AMOUNT ($) AVERAGE DOWN PAYMENT ($)

STATE AND FEDERAL TAX ID/SSN # OF PARTICIPATING LOCATIONS MONTH / YEAR STARTED LENGTH OF CURRENT OWNERSHIP

Is the business delinquent on any federal, state and/or payroll taxes? If yes, please explain Is the company involved in any pending lawsuits or litigation? If yes, please explain

SECTION #3 PRINCIPAL INFORMATION FULL NAME & TITLE (1) Is the company involved in any pending lawsuits or litigation? If yes, please explain

FULL NAME & TITLE (2)

HOME STREET ADDRESS HOME STREET ADDRESS


HOME PHONE MOBILE HOME PHONE MOBILE PHONE

% OWNERSHIP DOB SSN # % OWNERSHIP DOB SSN #

Has the business or principal #1 filed for bankruptcy protection? If yes, please explain Has the business or principal #2 filed for bankruptcy protection? If yes, please explain

SECTION #4 REFERENCES

BANK NAME CONTACT NAME CHECKING ACCOUNT NUMBER BANK PHONE

LANDLORD/MORTGAGE HOLDER PHONE BUSINESS FACILITIES

OWN RENT LEASE

SECTION #5 FEE SCHEDULE (TO BE COMPLETED BY SALES REPRESENTATIVE)

MERCHANT PAYOUT RANGE 60% TO 95%

Based on buyer CREDIT PROFILE

REPRESENTATIVE NAME

REPRESENTATIVE OFFICE NUMBER

MERCHANT SET UP FEE $195 (waived if enrolled in check pay program)

REPRESENTATIVE COMPANY

ISA NUMBER

MONTHLY MEMBERSHIP FEE $49.95* EMAIL

1 A funded loan processing fee of $9 will be charged per ACH transaction and $29.95 for checks sent via FedEx overnight. *Fee is due at the beginning of each membership month. The undersigned certifies that all information provided is true and correct and authorizes DiversePayments.com, LLC and its affiliates and any credit bureau or other agency to investigate the references, statements, or other data listed or accompanying this application. The undersigned authorizes all party’s contacts to release credit and financial information requested as a part of any due diligence.

SIGNATURE PRINTED NAME & TITLE DATE


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MERCHANT AGREEMENT

This Agreement is entered into this day of 20___ , by and between DiversePayments LLC, with offices at 23175 La Cadena Drive, Suite B, Laguna Hills, CA 92653 together with its contracted funding institutions (hereinafter called “COMPANY”), and the below identified Consumer goods and/or Services Provider (hereinafter called “Merchant”).

MERCHANT NAME PHONE FAX

ADDRESS CITY ST ZIP

Additional offices location(s) of Merchant that are listed in the Merchant Sign-up Form, which is attached hereto as Schedule A, shall be covered by this Agreement.

In consideration of the mutual promises and covenants contained herein, the parties agree as follows:

1. Purpose. Merchant is a medical practitioner or dealer, and is engaged in the retail sale of medical industry services including but not limited to specific treatment products and similar items (collectively “Products”). COMPANY has established a Consumer Finance Program for Consumer Goods and/or Service Providers pursuant to which COMPANY may finance qualified customer purchases of consumer goods and/or services from authorized Merchants. Merchant desires to participate in the COMPANY Program and desires to make such financing available to qualifying customers (hereinafter called “Borrowers”) who purchase consumer goods and/or services from Merchant. This Agreement sets forth the terms and conditions of Merchant’s participation in the COMPANY Program.

2. Referral of Borrowers. Merchant will refer to COMPANY prospective Borrowers who desire to obtain closed-end consumer installment loans to purchase consumer goods and/or services. If COMPANY chooses not to provide a loan to the prospective Borrower, then Merchant shall have the right to promote another financing source to the prospective Borrower. COMPANY will make loans only to such referrals as COMPANY deems acceptable, with each loan made solely at COMPANY’s election and sole discretion. Nothing contained herein obligates COMPANY to make any loans.

3. Documentation. COMPANY will provide Merchant with reasonable quantities of credit applications, related financing material, or access to the COMPANY controlled website, by which Merchant may retrieve such materials, which COMPANY deems necessary for Merchant and its customers to participate in the COMPANY Program.

4. Merchant’s Responsibilities. Merchant will take credit applications, verify prospective Borrower’s identity with a valid form of identification, and input preliminary credit data. COMPANY shall not compensate Merchant for the referral of Borrowers. Merchant will not submit any Note to COMPANY for funding until the consumer goods and/or services have been delivered and accepted by the Borrower.

5. Closing of Loans. In the event a referral from Merchant to COMPANY is approved and a loan transaction is consummated (“Closed Loan”), such loan transaction will be closed in the name of COMPANY and COMPANY will, at the direction of the Borrower, disburse to Merchant from the loan proceeds an amount equal to the amount financed by the Borrower for the consumer goods and/or services being purchased, less such adjustments to which COMPANY is entitled in the normal course of business which includes any amount owed COMPANY for Merchant Fees (per Schedule B) associated with the COMPANY Program (“Disbursement”). COMPANY shall make the Disbursement to Merchant’s deposit account(s) at the financial institution(s) designated by Merchant on the Merchant Sign-up Form, as the account(s) to be debited and/or credited, as applicable, for the settlement of Closed Loans and the payment of any Merchant Fees, discounts and charges due hereunder (“Settlement Account”) COMPANY shall, in its sole discretion, determine the maximum amount that it will finance for any Borrower.

6. Method and Timing of Settlement. COMPANY shall disburse to Merchant the Disbursement through the Automated Clearing House Network (“ACH Network”) by the fifth Business Day after the date of receipt of a signed and executed Note and other required loan documentation by Borrower. Merchant hereby (i) agrees to be bound by the terms of the operating rules of the National Automated Clearing House Association, as in effect from time to time, and (ii) authorizes COMPANY and its designated agents and representatives to initiate credit or debit entries and adjustments to the Settlement Account. COMPANY shall not be liable for any delays in receipts of funds or errors in Settlement Account entries caused by third parties. The following obligations of Merchant will survive the termination of the Agreement. Merchant shall not close the Settlement Account without providing COMPANY at least five (5) Business Days prior written notice of such closure and substitution of another account. Upon termination of the Agreement, Merchant agrees to maintain the Settlement Account with sufficient funds until such time as COMPANY has processed all Chargebacks (as hereinafter defined) and other adjustments and Merchant agrees to permit COMPANY to credit and debit such Settlement Account until all charges, Chargebacks and other adjustments are settled as provided for in this Agreement. Merchant shall be solely liable for all fees and costs associated with the Settlement Account. This authority will remain in effect until five (5) Business Days after COMPANY receives written notice from Merchant of its cancellation of such authorization, provided that in the event of termination of this Agreement, Merchant agrees to maintain the Settlement Account with sufficient funds until such time as Merchant and COMPANY agree that all Chargebacks and other adjustments are processed and to permit COMPANY to credit and debit such Settlement Account until all charges, Chargebacks and other adjustments are settled as provided in this Agreement. COMPANY shall not be liable to Merchant for any delays in the receipt of funds or errors in credit entries caused by Merchant or by third parties including, but not limited to, a clearinghouse, Merchant’s financial institution, or any agent of Merchant.

7. Billing Inquires and Disputes. COMPANY will notify Merchant when a Borrower has made a billing inquiry or filed a billing error notice relating to a Closed Loan. Merchant agrees to investigate and make a good faith effort to resolve each billing inquiry or dispute referred to it by COMPANY or received directly from a Borrower. Within fifteen (15) Business Days from the date COMPANY sends a billing inquiry or dispute to Merchant, Merchant shall notify COMPANY in writing of the resolution thereof or the action Merchant will take to resolve the billing inquiry or dispute. Merchant shall provide COMPANY with all such information as COMPANY may reasonably request in connection therewith.

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8. Chargeback Rights and Procedures.

a. Chargeback Rights. If Merchant has not complied with the terms of this Agreement or the standard operating procedures of COMPANY with respect to either the Merchant’s Responsibilities or a Closed Loan, or if, at the end of the fifteen (15) Business Days billing inquiry/dispute resolution period specified in the Agreement, the billing inquiry or dispute is not resolved (or COMPANY has not been informed of the resolution or the action Merchant will take to resolve the billing inquiry or dispute), COMPANY may refuse to pay Merchant for a Closed Loan or require the Merchant to reimburse COMPANY for a Closed Loan for which Merchant was previously paid in the amount of the loan, the account balance or the disputed portion thereof, as applicable, or set off from any future funding due Merchant an amount equal to all disputed amounts (a “Chargeback”). If COMPANY processes a Chargeback and the disputed amount is subsequently paid by the Borrower, COMPANY will reimburse Merchant for the disputed amount.

b. Method of Recourse. COMPANY is not required to pay Merchant for a Closed Loan which is being charged back. If COMPANY has already paid Merchant for such Closed Loan, COMPANY, at its sole discretion, may deduct the amount to be charged back from the Settlement Account or offset such amount from a future payment to Merchant. Alternatively, COMPANY may demand that Merchant pay COMPANY the amount of the Chargeback and Merchant shall make such payment within three (3) Business Days of such demand. Any Chargebacks which are not paid by aforesaid means shall be due and payable by Merchant promptly on demand.

c. Product Returns. In the event of a product return COMPANY will require Merchant to reimburse COMPANY an amount equal to the amount funded for the return item’s purchase. In addition, for a return item between 30 and 60 days from the Borrower’s acceptance of the loan, COMPANY will be entitled to receive from Merchant a fee equal to two percent (2%) of the principal balance of the Closed Loan. For return items between 60 and 90 days an additional 1% will be charged (total of 3%). For return items after 90 days from the Borrower’s acceptance of the loan the full payoff of the loan will be required to close the Borrower’s account.

d. Compliance with Laws. Notwithstanding anything to the contrary contained herein, in the event a Borrower, in accordance with the provisions of applicable state law or the federal Truth in Lending Act and Regulation Z, as they may be amended from time to time, files with COMPANY a billing error inquiry or alleges a quality dispute with respect to the consumer goods and/or services purchased from Merchant, COMPANY has the right of Chargeback against Merchant with respect to the Closed Loan which is the subject of such inquiry or dispute.

9. Merchant’s Warranties and Representations. Merchant hereby warrants and represents: (i) the accuracy and completeness of all documents and other information obtained or prepared by itself and by prospective Borrowers and others and submitted to COMPANY, (ii) that it will comply with COMPANY’s policies and procedures and all applicable federal, state, and local laws, ordinances and regulations including, but not limited to, the Equal Credit Opportunity Act and all regulations promulgated thereto; (iii) that the price charged to the Borrower as evidenced by the loan documentation is the same price that would be charged to the Borrower regardless of whether the Borrower pays cash for the consumer goods and/or services or utilizes the COMPANY Program; (iv) that it holds all licenses required in order to conduct its business as contemplated by this Agreement; (v) that it will deliver to the Borrower all loan disclosures, including, but not limited to, COMPANY’s Privacy Policy, required by COMPANY; (vi) that it is duly organized, validly existing and in good standing under the laws of the State of ____________ has full power and authority to carry on its business as it is now being conducted and is duly qualified to transact business as it is now being conducted in all states where such qualification is required; and (viii) that entering into this Agreement does not violate Merchant’s charter, certificate of organization, by-laws, or similar organizational documents as the case may be, nor any contract or agreement to which Merchant is a party.

10. Merchant’s Covenants. Merchant covenants to COMPANY that Merchant will (i) at all times and to all persons accurately represent the terms and conditions of the financing available under the Program as established by COMPANY from time to time; (ii) take all steps necessary to insure that the consumer goods and/or services are sold to Borrowers free and clear of any liens; (iii) keep secure all information with any company not affiliated with COMPANY, (iv) use its reasonable best efforts to fulfill all service obligations agreed to by Merchant with Borrowers; (v) perform warranty work promptly and as necessary in conjunction with Merchant’s warranty obligations to Borrowers, (vi) not use COMPANY’s name or logo in any written material or advertisement, without COMPANY’s prior written approval; and (vii) timely investigate all Borrower complaints related to consumer goods and/or services or Merchant services and resolve any legitimate Borrower complaints in a reasonable amount of time. In addition, Merchant will not use nonpublic personal information obtained from an applicant in connection with a loan application for any purpose not related to the loan application without the Borrower’s or COMPANY’s express prior approval. Further, Merchant will establish a system to store and maintain, in the original, signed credit applications and signed loan documents in such a manner so as to allow Merchant to forward, within twenty four (24) hours, copies of any signed credit applications or signed loan documents requested by COMPANY on behalf of a Customer. Such records are to be maintained for a period of twenty five (25) months from the date of funding.

11. COMPANY Not Bound; Merchant Indemnification. COMPANY will not be bound by any representations or promises made to prospective Borrowers by Merchant, its employees or agents. Merchant indemnifies and holds harmless COMPANY, its directors, officers, employees, and affiliates from any and all damages, losses, suits, claims, actions, costs or expenses, including attorney fees and court costs, relating to any claim, cause of action or liability of any kind whatsoever arising from: (i) any representations or promises made by Merchant, its employees or agents in connection with the sale, fitting and customization of medical service s, and the making of any loan to prospective Borrowers referred by Merchant to COMPANY, or any breach by Merchant of any promised representation, warranty, or agreement it has made herein or of any term or provision hereof or (ii) the death or injury to any person or the loss, destruction, or damage to any property arising out of the furnishing by Merchant of consumer goods and/or services.

12. Relationship of Parties. Merchant and COMPANY each will be acting independently at all times on its own behalf, and nothing contained herein may be construed to create the relationship of principal and agent or employer and employee between Merchant and COMPANY. Merchant will not make any representation that might cause any third party to conclude or reasonably understand the Merchant is an agent of COMPANY or is otherwise authorized to act on behalf of COMPANY in any respect, except to assist the customer in collecting and transmitting information relating to the loan application to COMPANY. Each party is an independent contractor. Each party further agrees that the relationship created by this Agreement is non-exclusive.

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13. Program Fees. The Merchant agrees to pay a discount computed by applying the Merchant Payout Rate (expressed as a percentage) to the amount of each contract assigned by merchant to Company. The precise Payout Rate will be provided on Company’s website for each credit-approved application. Merchant agrees to that discount when the merchant “certifies” the application electronically on Company’s website and/or submits required final documents from the applicant. The merchant shall also pay a funded loan ACH processing fee of $9 per ACH transaction for funded loans. The merchant shall pay a Monthly Membership Fee of $49.95. This fee shall be debited from the Merchant deposit account on or about the first business day of each month.

14. Termination. This Agreement may be terminated at any time by either party upon thirty (30) days prior written notice to the other, except in the event of a default by either, in which case the non-defaulting party may immediately terminate this Agreement by notifying the defaulting party that it is doing so. In addition, if there is a material change in any law or in regulatory conditions affecting the financing program contemplated hereunder or in the financial condition of Merchant this Agreement shall likewise be automatically terminated as of the same termination date. Termination of this Agreement will not affect the right and obligations of either party to this Agreement including, without limitation, any amounts then or thereafter owing by either party to the other, with respect to any Borrowers referred or loans closed prior to the effective date of any termination notice.

15. Non Circumvention, Confidentiality and Non-Compete. The Merchant agrees not to solicit or accept solicitation from any lender, investor, or financing source that has/have a financial relationship with the Company during the term of this contract and twelve months period thereafter without written permission by the COMPANY. Merchant also agrees not to enroll in any lender program affiliated with the COMPANY during the term of this contract and a period of twelve months thereafter.

16. Program Adjustments. A summary of the current features and Merchant Fees of the COMPANY Program is set forth in Schedules B & C. COMPANY reserves the right at any time to make adjustments to this Agreement, and Schedules hereto, and their terms and conditions.

17. Notice. Any notice given by either party under this Agreement must be addressed to the other at its address first shown above.

18. Payments for the Benefit of COMPANY. In the event Merchant receives any payment from any source (other than COMPANY) in connection with a loan referred to COMPANY by Merchant, Merchant shall be deemed to have received such payment(s) exclusively for the benefit of COMPANY and shall immediately forward such payments to COMPANY.

19. Integration: Authorization: Binding Agreement. This Agreement constitutes the entire agreement between the parties hereto and supersedes any and all representations, promises, and statements, oral or written, in connection with the subject matter of this Agreement and the negotiation hereof, and no such representation, promise, or statement not written herein shall be binding on the parties. This Agreement may not be varied or altered nor its provisions waived except by an agreement in writing executed by duly authorized agents of both parties hereto. The individual signing below on behalf of each party is duly authorized by such party to execute this Agreement on its behalf. This Agreement shall be binding upon and inure to the benefit of the parties hereto and each of their respective successors and assigns.

20. Severability. Any provision of the Agreement, which is prohibited or unenforceable in the jurisdiction, shall, as to such jurisdiction, be ineffective to the extent of such prohibition or unenforceability without invalidating the remaining provisions hereof, and any such prohibition or unenforceability in any jurisdiction shall not invalidate or render unenforceable such provisions in any other jurisdiction.

21. Waivers: Remedies. The waiver of any breach, term, provision, or condition of this Agreement shall not be construed to be a subsequent waiver of any other breach, term, provision, or condition. All remedies afforded by this Agreement for a breach hereof shall be cumulative; that is, in additional to all other remedies provided by herein or at law or in equity.

22. Survivability. All agreements, representations, warranties, and promises made herein shall survive the execution and delivery of this Agreement and the closing of loans hereunder.

23. Counterparts. This Agreement may be executed in one or more counterparts or duplicate originals, each of which shall be deemed an original, but all of which together shall constitute but one and the same instrument.

24. Governing Law. This Agreement shall be governed by, and construed in accordance with, the laws of the State of Utah, without regard to its rules as to conflicts of laws.

25. Jury Trial Waiver. Both Merchant and COMPANY hereby waive their right to trial by jury relating to any breach of this Agreement.

26. Assignability. Merchant may not assign any of its rights or obligations hereunder without the prior written consent of COMPANY. COMPANY may assign any or all of its rights and obligation hereunder to a separate lending party for execution of this Agreement.

IN WITNESS WHEREOF the undersigned have executed this Agreement as of the day and year first written below. The parties hereto agree that facsimile signatures shall be as effective as if originals.

MERCHANT NAME (Please print)


Signer(s) further asserts that he or she is a duly authorized officer or representative of Merchant. “COMPANY” DiversePayments LLC


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CORPORATE RESOLUTION

THIS DOCUMENT MUST BE COMPLETED IF YOU ARE A CORPORATION

CERTIFIED COPY OF CORPORATE RESOLUTION

This is to certify that a Special Meeting of the Board of Directors of NAME OF COMPANY-PRACTICE

a STATE

corporation (the “Corporation”), duly called and held on the day of DATE

in the principal office of the corporation in LOCATION

at which a quorum was present, the

following resolution was unanimously adopted:

WHEREAS, the TITLE

Of this CorporationNAME OF COMPANY OFFICER

, (hereinafter, “Designated Signatory”) is about to execute a DiversePayments.com, LLC Agreement (Agreement)

with DiversePayments.com LLC (the “Company”) in Laguna Hills, California, setting forth the Company’s and the

Corporation’s rights and responsibilities with respect to the origination of certain loans by the Corporation acting

on behalf of the Company and/or the purchase of certain contracts from the Corporation by the Company.

WHEREAS, it is the opinion of this Board of Directors that the execution of the Agreements is in the best interests

of this Corporation and that the consideration offered by the Company thereunder is fair and adequate;

NOW, THEREFORE, BE IT RESOLVED: that the execution of the Agreement by the Corporation for such

consideration and upon such terms and conditions and with such covenants, representations and warranties and

under such other terms and conditions as said Designated Signatory may deem sufficient, necessary or desirable,

be and the same is hereby authorized, approved and ratified as the act and deed of the corporation.

Furthermore, the Designated Signatory is hereby authorized to execute any and all other documents and to do

whatever else is necessary and proper to implement this Resolution.

IN WITNESS WHEREOF, I have hereto set my hand and the seal of this corporation on DATE

Corporate Secretary‐Signature

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ADDITIONAL LOCATIONS

LOCATION LOCATION

MERCHANT NAME MERCHANT NAME

STREET ADDRESS STREET ADDRESS


OFFICE PHONE FAX OFFICE PHONE FAX

LOCATION LOCATION





LOCATION LOCATION





LOCATION LOCATION





LOCATION LOCATION





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OFFICE TEAM ROSTER

You can maximize your revenue if you include financing options early in the process.

We strongly encourage you to include your staff that assists your customers in DiversePayments information and training sessions.

**Each individual user must have his/her own unique email address.

MEMBER MEMBER

FIRST & LAST NAME FIRST & LAST NAME

JOB TITLE DIRECT PHONE NUMBER JOB TITLE DIRECT PHONE NUMBER

E-MAIL EMAIL

LOCATION LOCATION

MEMBER MEMBER



E-MAIL EMAIL

LOCATION LOCATION

MEMBER MEMBER



E-MAIL EMAIL

LOCATION LOCATION

MEMBER MEMBER



E-MAIL EMAIL

LOCATION LOCATION

MEMBER MEMBER



E-MAIL EMAIL

LOCATION LOCATION

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ACH (Automated Clearing House Payment) Authorization Agreement I hereby authorize DiversePayments.com, LLC to initiate debit entries to my account with the Financial Institution indicated below

for the purpose of collecting monthly membership fees or other charges as they become due and payable under the terms and

conditions of the attached Me r c h a n t A g r e em e n t . I also authorize DiversePayments.com, LLC to initiate credit entries

to my account with the Financial Institution indicated below for the merchant payout minus a $9/funded loan ACH

processing fee for the customer loans that are funded under the terms and conditions of the attached Me r c h a n t

A g r e em e n t . This authority is to remain in full force and effect until DiversePayments.com, LLC has received written

notification from me of its termination in such time and in such manner as to afford DiversePayments.com, LLC and the

Financial Institution a reasonable opportunity to act upon it.

SECTION BANK ACCOUNT INFORMATION

BANK NAME FIRST & LAST NAME (ACCOUNT HOLDER)

BANK ADDRESS BANK CITY BANK ST BANK ZIP BANK PHONE

TYPE OF ACCOUNT TRANSIT/ABA ROUTING NUMBER ACCOUNT NUMBER

CHECKING ACCOUNT SAVINGS ACCOUNT

VOIDED CHECK

(Please attach a voided check here)

I have verified with the Financial Institution that the account indicated above is capable of receiving an ACH Debit or Credit item

SIGNATURE PRINTED NAME DATE

Documents

GPPS Diverse