2018-205-E Health - Elavon credit card fees

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DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 POINT OF SALE EQUIPMENT OR SOFTWARE NETWORK: ® ELAVON [I OTHER # OF TIDS: ❑ A THIRD PARTY INTEGRATOR WILL BE USED FOR IMPLEMENTATION: VAR SERVICE PROVIDER (HOSTED): VAR (DISTRIBUTED): VENDOR: PRODUCT: VERSION: PURCHASE /SETUP LEASE ** SOFTWAREIWIRELESS QTY POS DESCRIPTION ITEM CODE TERMINAL OWNS REPROG FEE PRICE TERM MONTHLY RATE ANNUALFEE MONTHLY FEE PER AUTH ENCRYPT PER UNIT PER UNIT MONTHLY PER UNIT PER UNIT UNIT FEE @ @ @ @PER ❑ ❑ $ $ $ $ W $ ❑ ❑ $ $ $ $ $ ❑ ❑ $� $ $ $ W Q @$ ❑ ❑ "'PLEASE NOTE THAT ALL LEASES MUST COMPLETE THE SECTION IMMEDIATELY BELOW. INITIALS ARE REQUIRED. ALL APPLICABLE STATE AND LOCAL TAXES WILL BE APPLIED. El SALES TAX EXEMPT Elavon and Member have no responsibility for, and shall have no liability to Company in connection with, any hardware or software, or any related services, Company receives under a direct agreement (including any sale, warranty or end -user license agreement) between Company and a third party, including any Value Added Sewicer, even if Elavon collects fees or other amounts from Company with respect to such hardware, software or services. DESCRIPTION SETUP FEE ANNUAL FEE MONTHLY FEE PER AUTH FEE [ADDITIONAL POS SERVICES: � @ $ @ $ $ TERMINAL PROGRAMING INSTRUCTIONS DO NOT USE FOR CONVERGE —THIS INFORMATION IS COVERED DURING TRAINING ❑ RETAIL AUTO CLOSE DEFAULT QUICK CLOSE El STORE AND FORWARD El NO SIGNATURE ❑ CONTACTLESS + NO SIGNATURE ❑ RESTAURANT (QUICK CLOSE DEFAULT) TIP FUNCTION (DEFAULT) ❑ FINE DINING ❑ TAB FUNCTION ❑ CARD NOT PRESENT (AUTO CLOSE DEFAULT) ❑ QUICK CLOSE ❑ LODGING (QUICK CLOSE DEFAULT) ❑ QUICK STAY CUSTOM PROMPTS: El TERMINAL AUTO CLOSE (RTL, MOTO) TIME ZONE El CASH BACK PIN DEBIT (RTL): $ (MAx) ❑CUSTOM FOOTER: ❑ NO TIP (REST) ❑ NO SERVER PROMPT (REST) ❑ CLERK PROMPT (RTL) ❑ TIP FUNCTION WAITER (RTL) ❑ TIP FUNCTION CASHIER (RTL) COMMUNICATION METHOD (IP DEFAULT): ❑ DIAL TRAINING (DEFAULT = TRAINING REQUIRED): ❑ NO TRAINING I PHONE INFORMATION: ACCESS #: X I understand that I am entering into a -month commercial equipment lease for credit -card processing equipment. I understand this is a NOW CANCELLABLE commercial equipment lease and that I will be required to make monthly payments of $ under this lease for the entire -month term, regardless of any representations made by the Sales Representative. Under a -month term with a monthly payments of $ , I understand the approximate total cost equipment lease to be $ . I also realize that I will have to pay applicable sales tax every month and, if I do not provide evidence of insurance, I will be charged an l nal $4.95monthly to cover equipment. I understand the equipment lease may be more expensive than purchasing the same equipment outright, and that I have had an nity to research the cost to purchase the same equipment outright. As an alternative to a lease, I understand I may purchase the equipment outright at the time of the lease appcation for the amount of $ Finally, I understand that I will be personally responsible for making payments under this lease and that any failure to pay all amounts when due may result in additional charges, potential damage to my credit rating, and /or legal action against me to collect both past and future payments owed under the lease. The end of lease residual value is $ plus taxes if applicable. Company hereby authorizes Elavon, through its Ladco Leasing division ( "Lessor'), to automatically withdraw Company's monthly lease payments and any amounts, including any and all taxes or other charges, owed in accordance with the lease, as applicable, by initiating debit entries to Company's account at the financial institution ("Bank ") indicated hereon or such other financial institution used by Company from time to time. A lease payment (whether paid by debit or other means) that is not honored by Bank for any reason will be subject to a returned item service fee imposed by Lessor. Upon completion of the lease term, this authorization shall remain in effect until Lessor has received written notice from Company of its termination. I, BANK NAME: I ABA/ROUTING #: IDDA ACCOUNT #: ELECTRONIC CHECK SERVICE ►ANNUAL CHECK VOLUME: $ ►AVERAGE CHECKAMOUNT: $ /MAXIMUM CHECK AMOUNT: $ /ECS MONTHLY MINIMUM: $ ECS — PAPER CHECK CONVERSION PROCESSING OPTIONS: ❑ CONVERSION WITH GUARANTEE GUARANTEE RATE: % PER TRANSACTION: $ ❑ POP (POS IMAGE) @ ❑ CONVERSION W/ VERIFICATION OR PER TRANSACTION: $ PER RETURN TRANSACTION: $ ❑ El ARC (POS IMAGE) ❑ BOC ❑ CONVERSION ONLY COLLECTIONS ACH CHECK —CHECK NOT PRESENT (CNP) PROCESSING OPTIONS: ❑ CONCURRENT ENROLLMENT (INCLUDES: WEB, TEL, PPD AND CCD) = XNP @ PER TRANSACTION:.PO INDIVIDUAL ENROLLMENT - CHOOSE ONE (ONE PER MID) ❑ ACH - ECHECK W ITH VERIFICATION ❑ WEB —INTERNET INITIATED ❑ PPD — PREARRANGED PAYMENT PER RETURN TRANSACTION: p TION: El TEL /IVR — TELEPHONE INITIATED El CCD — CORPORATE TO CORPORATE PER TRANSACTION: $ ❑ ACH — ECHECK CONVERSION ONLY CONVERGE SETUPS WILL BE CONCURRENTL Y ENROLLED INALL PRODUCT TYPES =XNP @ PER RETURN TRANSACTION: $ OTHER ECS CHECK CONVERSION SERVICE REQUESTS ❑ PROMPTS FOR DRIVER'S LICENSE (IF NOT ❑ NSF SERVICE FEE PROCESSING @ $2 PER NSF ITEM. NOT APPLICABLE FOR GUARANTEE S ERVICE SELECTED, INFORMATION MUST BE OBTAINED C1 @@ NSF SERVICE FEE AMOUNT: MAX ALLOWED OR ❑ SPECIFIED SERVICE FEE AMOUNT .p (STATE MAX IS DEFAULT) ON CHECK FOR GUARANTEE SERVICE) @ ACH ECHECK NSF SERVICE FEE AMOUNT: El .P1 S (DEFAULT) OR ❑ SPECIFIED SERVICE FEE AMOUNT SPECIFY NSF RESUBMISSION ATTEMPTS: ❑ 0 OR ❑ 1 (2 IS THE DEFAULT) ❑ ENQUIRE REPORTING ACCESS: # OF USERS: @ $29.95 EACH PER ACH — ECHECK QUESTIONNAIRE 1. WHAT TYPES OF PAYMENTS WILL YOU ACCEPT USING ACH - ECHECK (E.G., UTILITY BILL PAYMENTS, MONTHLY RENT PAYMENTS, MONTHLY BILLING FOR GENERAL SERVICES)? 2. WILL YOU OBTAIN AUTHORIZATION FROM YOUR CUSTOMERS PRIOR TO ACCEPTING AN ACH ENTRY IN ACCORDANCE WITH THE ECS OPERATING GUIDE (E.G., ORALLY VIA TELEPHONE FOR TEL/IVR, OR IN WRITING FOR PPD)? ❑ YES ❑ No 3. WILL YOU VERIFY AND AUTHENTICATE THE IDENTITY OF YOUR CUSTOMERS IN ACCORDANCE WITH THE ECS OPERATING GUIDE PRIOR TO INITIATING ACH ENTRIES FOR THOSE CUSTOMERS (E.G., BY OBTAINING A CUSTOMER'S NAME, ADDRESS AND TELEPHONE NUMBER OR USING A DATABASE TO VERIFY THE ACCURACY OF THE INFORMATION PROVIDED BY CUSTOMER)? ❑ YES []No 4. W ILL YOU OFFER ACH - ECHECK TO EXISTING OR NEW CUSTOMERS? ❑ EXISTING ❑ NEW 5. WILL YOU MAINTAIN AND DISCLOSE TO YOUR CUSTOMERS PROCEDURES FOR CANCELLING AN AUTHORIZATION? ❑ YES ❑ No 6. WILL YOU ENSURE THAT INFORMATION REGARDING EACH TRANSACTION AUTHORIZATION ENTERED BY A CUSTOMER AND /OR YOUR SERVICE REPRESENTATIVE IS ACCURATE AND NOT A DUPLICATE TRANSACTION? ❑ YES ❑ No USA- GOV -ELV -0218