ACH Underwriting Fee Payment

RESELLER CONTACT INFORMATION
Gateway Name: / Reseller Name:
Salesperson Name: / E-mail Address:
Mailing Address: / Office Phone Number: / Mobile Phone Number:
() -ext / () -
City: /
State:
/
Zip Code:
/ Office Fax Number: / Other Phone Number:
() - / () -
MERCHANT CONTACT INFORMATION
Merchant Name: / Your Merchant Contact: / E-mail Address:
Office Phone Number: / Mobile Phone Number: / Office Fax Number: / Other Phone Number:
() -ext / () - / () - / () -
PROPOSED FEES / RESELLER AGREEMENTS
There is no guarantee that your suggested deal can be accommodated
DO NOT make promises to the merchant regarding any terms or conditions / Are you providing the Credit Card Merchant Account for this Merchant?
Fee Description / Flat Fee / Discount Rate / Minimum Fee / Maximum Fee / Yes / Please include the information you obtained in the background check you performed on this merchant (Additional information may be required)
ACH Pre-Auth Fee / $0.00 / 0.00% / $0.00 / None / No
ACH Return Fee / $0.00 / 0.00% / $0.00 / None / Do you wish to waive the Underwriting Application Fee to the Merchant?
Check Unauthorized Return Fee / $0.00 / 0.00% / $0.00 / None / Yes / The Underwriting Application Fee may be charged to your account on file as allowed by your reseller agreement
Online Check NOC Fee / $0.00 / 0.00% / $0.00 / None / No / Please send the Underwriting Application Fee Agreement to the Merchant (Underwriting Application will not be considered without this)
ACH Credit/Payment
Auth Fee / $0.00 / 0.00% / $0.00 / None / Do you wish to act as GUARANTOR if Merchant fees and/of returned transactions become uncollectible?
ACH Credit/Payment Return Fee / $0.00 / 0.00% / $0.00 / None / Yes / You will be required to complete the GUARANTEE section of the ACH Underwriting Agreement before new limits are implemented
Debit for ACH Credit/Payment Return Fee / $0.00 / 0.00% / $0.00 / None / No / Some Underwriting Applications may be rejected without a GUARANTOR
Estimated Gross ACH Revenue: / Basis for Estimated Gross ACH Revenue:
$0 per month
Reseller Comments Regarding this Merchant:
Authorized Reseller Name (Please Print): / Authorized Reseller Signature: / Date:
Please fax the completed Proposal to 310-826-0404
UNDERWRITING REVIEWER REPORT
Underwriting Checklist
Obtained / Criteria / Ideal Applicant / Findings / Acceptable
Yes No / Standard Return Rate / 3.00% Maximum / Yes No
Yes No / Unauthorized Return Rate / 0.50% Maximum / Yes No
Yes No / Authorization Method / Signed Contract or Check Conversion / Yes No
Yes No / Consumer Complaints / Minimal from BBB and Other Sources / Yes No
Yes No / Criminal Check / No SignificantHistory Within the Last 7 Years / Yes No
Yes No / Credit Check / Company and Owners in Good Financial Health / Yes No
Reviewer Comments Regarding this Merchant:
Reviewer Name: / Application Status: / But Rate Schedule: / Date:
Approved Denied Terminated / StandardNon-Standard

ACH Underwriting FeePage 1Updated 9/27/2018