Fill - Free fillable Account Application Please read the following information before PDF form

Account Application

Please read the following information before completing this form. You, including the Company and its Authorized Representative, are requesting one or

more Divvy Charge Card accounts issued by Cross River Bank (“Issuer”). DivvyPay, Inc. (“Divvy”) is the program manager for the Divvy Charge Card.

Divvy and Issuer are collectively “we” or “us” as used herein. By signing below, you acknowledge and certify that: 1) all of the information below is

complete and accurate and you authorize us to check with credit reporting agencies, credit references and other sources we deem appropriate in

investigating the information given; 2) you agree that the terms of use of the account and/or card(s) shall be governed by the Divvy Business Charge

Card Agreement (the “Agreement”); 3) the natural person signing below is either a proprietor, general partner or officer of the Company with authority to

enter into the Agreement; 4) if requested, you shall provide financial statements for the last two (2) years; 5) you authorize us to provide Veri-Tax, LLC

with your name, social security number, email address and Company’s Employer Identification Number for purposes of processing and submitting to the

Internal Revenue Service a Form 4506-T to obtain transcripts of (i) your tax returns and/or (ii) Company tax returns, (6) Issuer and Program Manager

may obtain reports about the condition and/or creditworthiness of your business and investigate such matters by making direct inquiries of businesses

where you have accounts and other counterparties with which you interact; if you are a natural person, you also authorize Issuer and Program Manager

to obtain consumer reports about you and to make direct inquiries of where you work and of people who know you, to the extent permitted by law; upon

your request, Issuer and/or and Program Manager will disclose whether a consumer report was requested and the name and address of any consumer

reporting agency that furnished the report; these authorizations are effective throughout the application process and term of the Agreement and do not

terminate until you have paid Issuer all that you owe on your account; and 7) Issuer may report information about our experience with you, in your

individual capacity, to consumer reporting agencies; furthermore, Issuer may report information about our experience with Company to non-consumer

reporting agencies. Late payments, missed payments, or other defaults in connection with this loan may be reflected on your credit report. If you believe

that Issuer has reported inaccurate information to a reporting agency, write to us at the address listed on your statement and Issuer will investigate the

matter. In addition, you understand that the Issuer may require a guarantee, letter of credit, surety bond, or other acceptable form of security in order for

you to receive credit. You also understand that credit on this account, once approved, will be extended by Issuer and there is no binding contract until

the Issuer approves your application for credit.

Program Manager: DivvyPay, Inc.

Issuer: Cross River Bank

Select Service and Billing Terms:

Billing and financial terms are subject to final credit approval. All payments due upon receipt by the payment due date provided on your billing statement which is based on final credit

approval by Issuer (subject to a five (5) day grace period for billing cycles of Weekly or longer).

Billing cycle: Expense Reporting: Interface to Divvy



Payment Method: ☐ Debit ACH – enrollment in Auto-Pay program (requires credit approval) ☐ Credit ACH – You will initiate payments or pre-pay

funds

Notes: (1) You will remit all funds (in full) due using the remittance method selected above and defined as follows: (a) “Debit ACH” refers to a debit initiated by Issuer or its designee (via

Automated Clearing House or other electronic means) against an account designated by you; (b) “Credit ACH” refers to a credit initiated by you, at your own expense, (via Automated

Clearing House or other electronic means) to an account designated by Issuer. (2) You are required to send or transmit its Issuer Account Number with each payment. (3) Issuer shall

apply all payments beginning with the oldest invoiced amounts through the most recently invoiced amounts. (4) If a payment is returned or rejected, Issuer, at its sole discretion, may

reduce or cancel your available credit limit, assess a return payment fee, and reserves the right to modify the remittance method and frequency.

By signing below, you agree on behalf of the Company and in your individual capacity to be bound by the Divvy Business Charge Card Agreement.

Executive Sponsor/Authorized Representative: ____________________________ Title: Print Name: Phone:

Social Security Number:  Date of Birth: Home Address: Date:

Issuer complies with federal law which requires all financial institutions to obtain, verify, and record information that identifies each company or person who opens an account.

What this means for you: when you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify Company, you as

Authorized Representative, and/or any Authorized Users (as defined in the Divvy Business Charge Card Agreement). We may also ask to see documentation, including

driver’s license(s) or identifying documents for Company.

ACH Authorization Agreement

(Enrollment in Auto-Pay Program)

Company hereby agrees to make payment of such amounts as Company and Authorized Representative may owe from time to time to Cross River Bank

(“Issuer”) pursuant to the Divvy Business Charge Card Agreement (collectively, the “Account Agreement”), as amended from time to time, between

Company, Authorized Representative, and Issuer. Company hereby authorizes Issuer, Program Manager, and their designees to initiate debit or credit

entries to Company’s demand deposit account at Company’s Bank, and further authorizes Company’s depository bank to accept such entries initiated by

Issuer and to debit or credit such entries to Company’s account without responsibility for the correctness of the entries. Issuer may make such debit or credit

entries at any time when amounts are due or payable under the Account Agreement. Company agrees to be bound by the NACHA Operating Rules in effect

when any debit or credit entry is submitted. PLEASE NOTE: COMPANY’S BANK MUST BE A MEMBER OF THE AUTOMATED CLEARINGHOUSE.

Any person signing this agreement on behalf of the Company hereby acknowledges that said person is duly authorized to do so and to bind the business to

this Agreement.

Authorized Representative: ______________________ Title: ______________________

Print Name: _______________________ Date: _______________________

Additional Terms and Conditions

1. Termination: This Agreement shall remain in effect until terminated upon fifteen (15) days’ notice by either Company or Issuer. Notice of

termination shall in no way affect debit or credit entries made prior to actual receipt of notice, and shall not affect Company's obligation to pay any amounts

owed.

2. Effect on Other Agreements: This agreement amends the terms and conditions of the Account Agreement. In the event of a conflict between this

and the underlying Account Agreement, the terms set forth herein shall apply.

3. Indemnification: Company agrees to indemnify and hold Issuer harmless from any claim or claims including without limitation any claims based on

losses due to (i) labor problems, breakdowns or other non-functioning of any equipment necessary for consummating the transfers contemplated by this

Agreement or other causes or circumstances beyond the control of Issuer, (ii) the acts or omissions of third parties, including without limitation Company's

bank, Issuer's bank, and Automated Clearing House Association, Federal Reserve Bank, Participating bank or courier services; and (iii) non-credit of any

deposit.

4. Funds on Deposit: Company agrees to maintain sufficient funds on deposit in Company's demand deposit account at Company's bank to pay in

full the total amounts debited to Company's account pursuant to this Agreement. If the Company's account contains insufficient funds to pay the amount of

any debit in full, Company shall be subject to the terms of the Account Agreement, as amended, between Company and Issuer with respect to payment by a

NSF instrument.

J&S Version

Divvy Business Charge Card Agreement

This Agreement explains the current terms and conditions of your Divvy

Business Charge Card Account, which is issued by Cross River Bank

(“Issuer, we, us, and our”) and administered with the assistance of DivvyPay,

LLC (“Program Manager”). See below for other important definitions.

Execution of this Agreement and/or use of the Card is acceptance of the

terms and conditions. Please read this Agreement carefully and keep a copy

for your records. If you have any questions, please contact us.

1. Acceptance of this Agreement

You accept this Agreement and consent to all of the terms and conditions

set forth if you, and Authorized Representative, or an Authorized User use

the Account, or if you do not cancel your Account within 30 days after

receiving a Card. You may, however, reject the “Arbitration” section as

explained below. If you are an Authorized User, Authorized Representative

and/or Executive Sponsor, you also accept this Agreement and consent to

all of its terms and conditions.

2. Changes to this Agreement

We may change the rates, fees and terms of this Agreement from time to

time, which may include adding, modifying or deleting any term to this

Agreement. If required by law, we will give you advance written notice of the

change(s) and a right to reject the change(s). Oral modifications to this

Agreement are not permitted.

3. Your Credit Line and Account

We will tell you what the credit line for your Account is. You must keep your

Account balance below your Account credit line. If you do not, we may

request immediate payment of the amount by which you exceed your

Account credit line. We may make changes to your Account credit line at

any time without notice. We may delay increasing your available credit by

the amount of any payment that we receive for up to 15 days.

You may use your Account to make charges for purchases at merchants

accepting a Card and any other transactions that we make available to you.

However, we may choose not to authorize any charge for security or other

reasons, and may do so in our sole discretion. We will not be liable to you if

we decline to authorize a charge or if anyone refuses your Card or Account

number. You must use your Account for commercial or business purposes.

You may not use your Account for illegal transactions or in a manner

inconsistent with this Agreement. No other person other than you and any

Authorized User is permitted to use the Account or the Card, and you must

take reasonable steps to prevent others from doing so. Provided however,

you are responsible for the usage of any person you permit to use the Card,

an “Authorized User”.

4. Authorized Users

You may request additional Cards for Authorized Users. Authorized Users

do not have accounts with us, but they can use your Account subject to the

terms of this Agreement. You are responsible for all charges made by any

Authorized User, regardless of whether you intended to be responsible for

such charges. You must promptly notify us if you wish to cancel the authority

of an Authorized User to use your Account and follow any instructions that

we provide. We may report an Authorized User’s use of your Account to

consumer reporting agencies. You authorize us to give Authorized Users

information, which may include non-public consumer information, about your

Account. If you are an Authorized User and have not already consented to

the terms of this Agreement, then you provide such consent if you use a

Card or do not return a Card provided to you within 30 days of receipt.

5. Account Controls

You may request that controls be applied to your Account. If you so request,

we will use merchant category codes (”MCC(s)”) to establish controls over

purchases made on the account. We may also limit your Accounts ability to

use certain MCCs. MCCs are chosen by merchants and assigned by the

Card Network. You agree that we have no responsibility for inaccurate or

inappropriate MCC assignments. We, however, will use commercially

reasonable efforts to deny requests for charges that fall outside the selected

MCC or control parameters; however, you remain responsible for payment

in full for all charges, even those that fall outside of the MCC or control

parameters selected. The existence and/or use of controls will not affect your

liability for unauthorized use of the Account. Only charges submitted for

authorization are subject to controls and those controls can only be enforced

when the merchant provides sufficient information as part of the

authorization. We may, in our sole discretion, at any time and without prior

notice, modify controls, including without limitation to prevent suspected

fraudulent activity. You agree that you are responsible for reviewing fraud

control data provided by us, for the purpose of detecting fraud that may occur

within control parameters.

6. Account Reporting

We may provide charge data for your Account, as transmitted by merchants

to us. If we do so, you agree that we are not liable for the accuracy or

completeness of such data or any related information services provided.

You understand that in the event an error is identified in a report, such as an

incorrect product code, you are still liable for a charge, subject to the other

terms of this Agreement.

7. Your Payments

You promise to pay all charges, fees, and other amounts arising from or

related to your account, including charges you make, even if you do not

present your card or sign for the charge, charges that other people make if

you let them use your Account, and charges that Authorized Users make or

permit others to make. You must pay the full Amount Due shown on each

of your statements no later than by its Payment Due Date.

You authorize us to apply payments and credits at our discretion, including

in a manner most favorable or convenient for us. If applicable law requires

that payments and credits be applied in a certain order, then we will do so.

8. How to Make Payments

You must pay us for all amounts due on your Account. This includes

transactions made by Authorized Users. You must pay in U.S. dollars. Do

not send cash. All checks must be drawn on funds on deposit in the U.S. at

a U.S. depository institution. We may refuse to accept a payment in a foreign

currency. If we do accept it, we will charge your Account our cost to convert

it to U.S. dollars. We can accept late payments, partial payments or

payments marked “payment in full” or with any other restrictive endorsement

without losing any of our rights under this Agreement.

You must make your payments in accordance with the terms contained on

your billing statement. If you mail your payment to an address other than

the address designated on your billing statement, there may be a delay in

processing and crediting the payment to your Account. If a third party makes

a payment on your Account and we return all or a part of such payment, then

we may adjust your Account for any amount returned. We have the right to

defend ourselves in connection with any demand to return funds we have

received, and may agree to a compromise of the demanded amount as part

of a settlement.

9. Joint Accounts

If more than one person is responsible for making payments on the Account

under this Agreement, then each of you agree that you are obligated to pay

all amounts owed to us in connection with the Account regardless of any

other obligated person. For example, your obligation to pay is not

discharged by the refusal of another to pay a portion of what is owed or by

the other party filing for bankruptcy. However, the total amount that we

collect from both of you cannot exceed the total amount owed in connection

with the Account. Any authorization by any person obligated to make

payments on the Account, and any authorization provided by an Authorized

Representative or Executive Sponsor for such person, is effective for and

J&S Version

binding on you. A default by any of you shall be considered a default by all

of you.

10. Fees

You agree to pay the fees as set forth in this Agreement. The amount of

each fee will be charged to your Account on the date it is due to us. When

a fee is charged to your Account, your available credit will be reduced by the

amount of the fee.

• Late Fee. If we do not receive the full Amount Due shown on your

statement by its Payment Due Date, then we may assess a late

fee equal to the greater of (i) 2.99% of all amounts past due on

your Account or (ii) $38.

• Returned Payment Fee. If any payment submitted on your

account is returned or dishonored, including without limitation for

nonsufficient funds, then we may assess a returned payment fee

of $38.

• Foreign Currency Transaction Fee. If any charge on your Account

is made in a currency other than U.S. dollars, then we may assess

a Foreign Currency Transaction Fee of up to 20 basis points

(0.20%) of the amount of such charge. Please also see

“Transactions Made in Foreign Currencies” for other important

information about charges made in foreign currencies.

• Cross Border Transaction Fee. If any charge on your Account is

made at a location outside of the United States in U.S. dollars,

then we may assess a Cross Border Transaction Fee of up to 90

basis points (0.90%) of the amount of such charge.

Notwithstanding the foregoing, in no event shall any fee or portion of such

fee be assessed if prohibited by applicable law. If any fee or portion of a fee

set forth above is finally determined to be prohibited by applicable law, then

we will not assess such fee or portion of such fee and will credit your Account

for any amounts received that otherwise would have been prohibited by

applicable law.

11. Transactions Made in Foreign Currencies

If you make a charge in a currency other than U.S. dollars, the Card Network

will convert it into a U.S. dollar amount. The Card Network will use its own

currency conversion procedures. The conversion rate in effect on the

processing date may differ from the rate in effect on the transaction date that

appears on your statement. As discussed above, we may assess a Foreign

Currency Transaction Fee on such charges and this fee is in addition to any

cost that you may incur due to the conversion procedures used by the Card

Network.

12. Prepaid Funds

We, in our sole discretion, may permit or require you to prepay money in

advance of making charges on your Account. If we do so, your prepayment

will be treated as a security deposit that has been paid to us. No interest will

be paid on prepaid funds and they will be treated as our funds, subject to

your contractual right to receive a payment credit for such amounts on the

Account. We may make some or all of your credit line dependent on the

prepayment of funds for your Account. If we do so, you agree that we may

automatically adjust your credit line based on the prepaid funds available to

us. When amounts on the Account come due, we may apply any prepaid

funds as a credit against the amounts that you owe. If the prepaid funds

available are not sufficient to pay all that you owe, then you must pay the

difference by the applicable payment due date. We may apply prepaid funds

to any amount that you owe us at any time without further notice to you. If

you authorize a charge that requires prepaid funds, but do not complete the

transaction, then the charge authorization may result in a hold of up to seven

(7) days for prepaid funds associated with such charge. We may prepay

funds only using the methods that we designate and such prepayments are

subject to any minimum, maximum, and frequency limits that we establish.

We may adjust any prepayment requirements in our sole discretion and

without prior notice to you.

13. Information Sharing

Except as prohibited by law, you authorize us to share information relating

to or arising from your Account, any Card, and your application for the

Account with any party affiliated with us to market to you, or for other

reasons, with merchants accepting a Card, with any Card Network, and with

other third parties to facilitate the operation of your Account.

14. Default

You are in default under this Agreement if:

• you do not comply with the terms of this Agreement, including

without limitation failing to make a required payment when due,

exceeding your Account credit line, or using your Card or Account

for an illegal transaction or transaction not permitted by the

networks or the terms set forth herein;

• you file bankruptcy or another insolvency proceeding is filed by

you or against you;

• we have a reasonable belief that you are unable or unwilling to

repay your obligations to us;

• you provide false or misleading information to us;

• you default under any other agreement you have with us; or

• you die or are legally declared incompetent or incapacitated.

If you are in default, then we may declare the entire balance of your Account

immediately due and payable without notice, except to the extent required

by law. We also may suspend your ability to make charges and/or cancel or

suspend any feature or service associated with your Account. If we use an

attorney to collect your Account, then we may charge you our legal costs to

the extent permitted by law. These may include reasonable attorneys’ fees,

court or other collection costs, and fees and costs of any appeal.

15. Notice of Loss, Theft or Unauthorized Use

If you or any Authorized User knows of or suspects the loss, theft,

compromise or possible unauthorized use of a Card or Account, you must

instructions on your statement.

16. Unauthorized Use

You are liable for all unauthorized charges on your Account unless:

• The unauthorized charge occurred after you provided us with

notice that a Card for your Account had been lost, stolen,

compromised, or involved in other unauthorized use, as required

by this Agreement, and we had a reasonable amount of time to

act upon such notice;

• You are a natural person or less than ten (10) Cards have been

issued on your account, in which case your liability for

unauthorized charges shall not exceed the lesser of $50 or the

amount of money, property, labor, or services obtained by

unauthorized use before you notified us of such unauthorized use;

• You are eligible for other protection from authorized charges

under the Card Network's rules and you have met all conditions

for such protection, in which case your liability will be limited in

accordance with such Card Network’s rules.

17. Disputes Regarding Charges on Your Account

You shall use your best efforts to resolve all disputes directly with any

merchant, including without limitation, disputes involving purchase price

discrepancies, quality, warranty, or performance issues. All charges must

be paid in full regardless of disputes, except to the extent otherwise required

by applicable law. If you have questions or wish to dispute a charge, you

must provide us with notice in writing no later than 60 days from the billing

date of such charge. If you do not provide notice within this time, charges

will be considered final and binding even if there was an error or basis for

dispute. If we determine that a charge qualifies for a chargeback to the

merchant, then we will initiate a chargeback under the Card Network rules.

Any accepted chargeback will be credited to your Account. You will not

pursue any claim against or reimbursement from a merchant if we have

J&S Version

credited your account for a chargeback. You will remain liable for any charge

that cannot be charged back to the merchant.

18. Communications

You authorize us to contact you by phone, electronic mail, or text message

at any phone number or address you provide, including without limitation

contacting you using automatic telephone dialing systems and/or

prerecorded/artificial voice messages, and you authorize such contacts even

if it involves a wireless telephone and/or results in charges to you.

Additionally, you authorize the Program Manager, our service providers,

debt collectors, collection attorneys, and other third parties working for us to

contact you using these methods. You also agree that we may monitor

and/or record our calls with you. You agree that any written notice or

disclosure, required by law or this Agreement, may be mailed or e-mailed to

the mailing address or e-mail address we have on file for you. It is your sole

responsibility to provide and maintain your current mailing address, email

address, and other contact information with us.

19. Credit Reporting

You authorize the Issuer and/or Program Manager to obtain reports about

the condition and/or creditworthiness of your business and to investigate

such matters by making direct inquiries of businesses where you have

accounts and other counterparties with which you interact. If you are a

natural person, you also authorize us to obtain consumer reports about you

and to make direct inquiries of where you work and of people who know you,

to the extent permitted by law. Upon your request we will disclose whether

a consumer report was requested and the name and address of any

consumer reporting agency that furnished the report. These authorizations

are effective throughout the term of this Agreement and do not terminate

until you have paid us all that you owe on your Account. If you are a natural

person, we may report information about our experience with you to

consumer reporting agencies. Late payments, missed payments, or

other defaults in connection with this loan may be reflected on your

credit report. If you believe that we have reported inaccurate information to

a consumer reporting agency, write to us at the address listed on your

statement and we will investigate the matter.

20. Closing Your Account

You may close your Account at any time by contacting us and (i) destroying

the cards or (ii) returning the cards to us. You will remain responsible for any

amounts you owe us under this Agreement and your Account and this

Agreement will not terminate until you pay all that you owe us under this

Agreement. We may close, cancel, suspend or not renew your Account at

any time without notice and for any reason.

21. Governing Law

This Agreement is governed by applicable federal law and by New Jersey

law (without regard to conflicts of law principles). However, in the event you

default and we file a lawsuit to recover funds loaned to you, the statute of

limitations of the state where the lawsuit is filed will apply, without regard to

that state’s conflicts of law principles or its “borrowing statute.”

22. Legal Notices

All notices relating to legal actions, including bankruptcy notices, must be

sent to us at Cross River Bank c/o DivvyPay, LLC, 13707 S. 200 W., Suite

100, Draper, UT 84020. Legal notices sent to any other address will not

satisfy any legal requirement that you provide notice to us.

23. Arbitration

RIGHT TO REJECT ARBITRATION. IF YOU DO NOT WISH YOUR

ACCOUNT TO BE SUBJECT TO THE FOLLOWING ARBITRATION

PROVISION, YOU MUST ADVISE US IN WRITING AT CROSS RIVER

BANK c/o DIVVYPAY, LLC, 13707 S. 200 W., SUITE 100, DRAPER, UT

84020. YOU MUST CLEARLY PRINT OR TYPE YOUR NAME AND

ACCOUNT NUMBER AND STATE THAT YOU REJECT ARBITRATION.

YOU MUST GIVE WRITTEN NOTICE; IT IS NOT SUFFICIENT TO

TELEPHONE US. WE MUST RECEIVE YOUR LETTER OR E-MAIL

WITHIN SIXTY (60) DAYS AFTER THE DATE YOUR ACCOUNT IS

ESTABLISHED OR YOUR REJECTION OF ARBITRATION WILL NOT BE

EFFECTIVE.

This paragraph describes how all Claims (as defined below) will be

arbitrated, at the election of you or us, on an individual (non-class, non-

representative) basis instead of litigated in court.

Definitions. The term Claim means any claim, dispute, or controversy

between you and us or the Program Manager arising from or relating to your

loan, your account with us, or this Agreement, as well as any related or prior

agreement that you may have had with us or the Administrator, or the

relationships resulting from this Agreement, including the validity,

enforceability or scope of this arbitration provision or the Agreement. Claims

arising in the past, present, or future, including Claims arising before the

execution of this Agreement, are subject to arbitration. Claim includes,

without limitation, claims that arise from or relate to any application for this

loan or any advertisements, promotions, or statements related to your loan.

For purposes of this Arbitration provision, you and us also includes any

corporate affiliates, any licensees, predecessors, successors, assigns, any

purchaser of any accounts, all agents, employees, directors and

representatives of any of the foregoing, and other persons referred to below

in the definition of Claims. Claim includes claims of every kind and nature,

including but not limited to initial claims, counterclaims, cross-claims, third-

party claims, and claims based upon contract, tort, fraud, and other

intentional torts, statutes, regulations, common law, and equity. Claims and

remedies sought as part of a class action, private attorney general action, or

other representative action are subject to arbitration on an individual (non-

class, non-representative) basis, and the arbitrator may award relief only on

an individual (non-class, non-representative) basis. Claim also includes

claims by or against any third party relating to or arising from your Card, your

Account, or this Agreement. The term Claim is to be given the broadest

possible meaning that will be enforced. Administrator means the American

Arbitration Association, 120 Broadway, Floor 21, New York, NY 10271,

www.adr.org, (800) 778-7879; or JAMS, 18881 Von Karman Ave., Suite 350,

Irvine, CA 92612, www.jamsadr.com, (949) 224-1810.

Right to Elect Arbitration. We OR you have the right to require that each

Claim be resolved by arbitration on an individual (non-class, non-

representative) basis. A Claim will be arbitrated if (1) both we and you or (2)

only one or the other of we or you, exercise the right to require that the Claim

be arbitrated. If, for example, we exercise our right to require that the Claim

be resolved by arbitration but you do not also exercise your right to require

that the Claim be arbitrated, the Claim will be resolved by arbitration. If

neither we nor you request arbitration, the Claim will not be resolved by

arbitration and instead will be litigated in court. We will not elect arbitration

for any Claim you file in small claims court, so long as the Claim is individual

and pending only in that court. The arbitrator's authority to resolve Claims

is limited to Claims between you and us alone, and the arbitrator's authority

to make awards or decisions is limited to you and us alone. Furthermore,

Claims between you and us may not be joined or consolidated in arbitration

with Claims brought by or against someone other than you, unless otherwise

agreed to in writing by all parties. However, borrowers and co-borrowers on

a single loan, or corporate affiliates, are considered one person for the

purposes of this paragraph. No arbitration award will have any preclusive

effect as to issues or claims in any dispute involving anyone who is not a

party to the arbitration. This arbitration provision is made pursuant to a

transaction involving interstate commerce and will be governed by the

Federal Arbitration Act (“FAA”) (9 U.S.C. § 1, et seq.).

No Jury Trial or Class Claims. If we or you request arbitration of a Claim,

we and you will not have the right to litigate the Claim in court. This means

(1) there will be no jury trial on the Claim, (2) there will be no pre-

arbitration discovery except as the Administrator’s rules permit, and

(3) no Claim may be arbitrated on a class-action, private attorney

general, or other representative basis, and neither we nor you will have

the right to participate as a representative or member of any class or

group of claimants pertaining to any Claim subject to arbitration. We

or you may elect to arbitrate any Claim at any time unless it has been filed

in court and trial has begun or final judgment has been entered.

Initiation of Arbitration. The party initiating an arbitration shall select an

Administrator from the organizations listed above. If none of the

Administrators listed above will accept the arbitration, the arbitration will be

administered by an administrator, or adjudicated by an arbitrator, upon which

you and we agree in writing. The arbitration shall be governed by the

procedures and rules of the Administrator and this Agreement, which need

not apply federal, state or local rules of procedure and evidence. The

Administrator’s procedures and rules may limit the discovery available to you

J&S Version

or us. You can obtain a copy of an Administrator’s procedures and rules by

contacting the Administrator. A single, neutral arbitrator will resolve Claims.

The arbitrator will be either a lawyer with at least ten years’ experience or a

retired or former judge, selected in accordance with the rules of the

Administrator. In the event of any conflict or inconsistency between this

arbitration provision and the Administrator's rules or other provisions of this

Agreement, this arbitration provision will govern. The arbitrator will take

reasonable steps to protect customer account information and other

confidential information if requested to do so by you or us. Arbitration

hearings for Claims by or against you will take place in the federal judicial

district in which you reside. If you make a request to us in writing, we will

temporarily advance to you the filing, administrative, and hearing fees for the

arbitration of your Claim against us (but not if the Claim is against you) in

excess of any filing fee you would have been required to pay to file the Claim

in a state or federal court (whichever is less) in the judicial district in which

you reside. At the end of the arbitration, the arbitrator will decide if you have

to repay the advance (and if you do have to repay, you agree to do so).

Unless applicable law requires otherwise, we will pay our, and you will pay

your, lawyers’, experts’, and witnesses’ fees. The arbitrator will apply

applicable substantive law consistent with the FAA and applicable statutes

of limitations, will honor claims of privilege recognized at law, and will have

the power to award to a party any damages or other relief provided for under

applicable law. The arbitrator will make any award in writing and, if

requested by you or us, will provide a brief statement of the reasons for the

award.

Arbitration Award and Appeals. Judgment upon the arbitrator’s award may

be entered in any court with jurisdiction. The arbitrator’s decision regarding

any claims will be final and binding, except for any appeal right under FAA.

The appealing party will pay the appeal costs. This agreement to arbitrate

shall survive any suspension, termination, revocation or closure of the

Agreement or your Account, and any bankruptcy to the extent consistent

with applicable bankruptcy law.

Enforcement of this Provision. If any part of this arbitration provision cannot

be enforced, the rest of the arbitration provision will continue to apply.

However, an arbitrator cannot enlarge his or her authority over the

adjudication of Claims beyond that provided by this arbitration provision by

enforcing only part of this arbitration provision. If an arbitrator determines

that applicable law requires this arbitration provision to be enforced in a way

that would result in greater authority over Claims than otherwise allowed,

such as the adjudication of claims on a class or representative basis, then

the arbitrator must decline to hear the dispute and shall refer the parties to

a court or other body with sufficient authority. In the event of any conflict or

inconsistency between this arbitration provision and the Administrator's rules

or other provisions of this Agreement, this arbitration provision will govern.

24. Other Terms and Conditions

If any part of this Agreement is found to be invalid, the rest of it will still

remain in effect (except as noted in “Arbitration” section above). We may

delay or not enforce any of our rights under this Agreement without losing or

waiving any of them. We may sell, assign or transfer your Account and/or

our rights and obligations under this Agreement (or any portion thereof)

without notice to you. You may not sell, assign or transfer your Account or

your rights and obligations under this Agreement without obtaining our prior

written consent. Nothing contained in this Agreement shall be construed as

constituting or creating a partnership, joint venture, agency, or other

association or relationship between you and us. To the extent that either

party undertakes or performs any duty for itself or for the other party as

required by this Agreement, the party shall be construed to be acting as an

independent contractor and not as a partner, joint venturer, or agent for the

other party. In no event shall we be liable to you for any failure or delay in

performance wholly or in part due to causes or circumstances beyond our

reasonable control including, but not limited to the following: acts of God;

acts of the public enemy; civil disturbance; war; acts of the United States of

America or any state, territory or political division of the United States of

America; fires; floods; natural disasters; pandemic or epidemic events,

regional, statewide, or nationwide strikes, or any other general labor dispute

not specific to us; and/or communication line failures (collectively “force

majeure”). Our inability to perform under this Agreement due to force

majeure events will not be considered a breach or default.

EXCEPT AS OTHERWISE REQUIRED UNDER LAW, WE ARE NOT

LIABLE FOR ANY LOSS SUSTAINED BY ANY PARTY RESULTING FROM

ANY ACT, OMISSION OR FAILURE TO ACT BY US OR THOSE ACTING

ON OUR BEHALF, WHETHER WITH RESPECT TO THE EXERCISE OR

ENFORCEMENT OF OUR RIGHTS OR REMEDIES UNDER THIS

AGREEMENT, UNLESS THE LOSS IS CAUSED BY OUR GROSS

NEGLIGENCE OR WILLFUL MISCONDUCT. OUR LIABILITY UNDER

THIS AGREEMENT SHALL BE LIMITED TO ACTUAL DAMAGES

INCURRED BY YOU AS A DIRECT RESULT OF OUR GROSS

NEGLIGENCE OR WILLFUL MISCONDUCT, IF ANY. FURTHERMORE,

OUR LIABILITY SHALL NOT EXCEED THE SUM OF ALL FEES PAID BY

COMPANY TO ISSUER UNDER THIS AGREEMENT PRIOR TO THE

DATE WHEN ANY CLAIM IS MADE AGAINST ISSUER. IN NO EVENT

WILL WE BE LIABLE FOR INCIDENTAL, SPECIAL, CONSEQUENTIAL OR

PUNITIVE DAMAGES.

EXCEPT AS OTHERWISE REQUIRED UNDER LAW, WE MAKE NO

WARRANTY WITH RESPECT TO GOODS, PRODUCTS OR SERVICES

PURCHASED ON CREDIT THROUGH US. WE FURTHER DISCLAIM ALL

WARRANTIES WITH RESPECT TO GOODS, PRODUCTS AND

SERVICES PURCHASED WITH A CARD, INCLUDING, WITHOUT

LIMITATION, THE IMPLIED WARRANTY OF MERCHANTABILITY.

25. Definitions

The following terms have the following meanings:

• Account means your credit account under this Agreement.

• Agreement means this Card Agreement, along with any other

document incorporated by reference.

• Amount Due means the amount due on your Payment Due Date,

as reflected on your billing statement.

• Authorized User means any person you authorize to use your

Account or a Card, whether you notify us or not.

• Card means any credit card, account number or access code, or

access device issued to you or someone else with your

authorization for your Account.

• Card Network means the Visa payment card network and any

other payment network through which charges may be submitted

or paid in connection with your Account or Card.

• Authorized Representative and Executive Sponsor means, if you

are not a natural person, any natural person acting on your behalf

during the process of applying for or establishing this Account.

• Payment Due Date means date that your Amount Due is due, as

reflected on your billing statement.

• You, your, and yours, means any person (legal entity or natural

person) named on a Card, who signed an application for an

Account, or who is contractually liable to make payments under

this Agreement. This includes, without limitation, any Authorized

Representative or Executive Sponsor (including the obligations to

pay) and, except for the obligations to pay contained in Section 7

(Your Payments) and Section 9 (Joint Accounts) above, any

Authorized User.

26. Other Notices

New Jersey Residents: Because certain provisions of this Agreement are

subject to governing law, they may be void, unenforceable or inapplicable in

some jurisdictions. None of these provisions are void, unenforceable or

inapplicable with New Jersey. The section headings of this Agreement are

not contract terms.

For Utah residents: This written agreement is a final expression of the

agreement between you and us and the written agreement may not be

contradicted by evidence of any alleged oral agreement.

J&S Version

DivvyPay, LLC Rewards Program

This DivvyPay, LLC Rewards Program agreement (“Rewards Agreement”) is entered into by and between DivvyPay, LLC (“Divvy” or “we”) and the Company identified below (“you”, and

“your”).

1. Divvy Rewards: You shall be eligible to receive points from Divvy for all purchases made with the Divvy charge card, excluding any cash advances, credits, chargebacks, bill payment

transactions, and Plastiq transactions (“Net Purchase(s)”), subject to and according to the details outlined herein (“Points”)(“Divvy Rewards”).

2. Points Accrual: Points are accrued on a per-transaction basis, and therefore total Point accrual cannot be determined until all transactions are completed, cleared and paid. Points are accrued

based on your Net Purchases paid on or before the “Payment Due Date” reflected on your billing statement for each Billing Cycle (as defined below) based on the multipliers table found at

getdivvy.com/rewards (“Divvy Rewards Table”), subject to reductions and restrictions, which may include, but are not limited to, those outlined herein. The Divvy Rewards Table may be

updated at any time, in Divvy’s sole and absolute discretion.

3. Points Conversion and Redemption: For your first twelve (12) months as a customer of Divvy, beginning on the date of your first Net Purchase, all Points accrued by you will be aggregated

on an annual basis, not subject to conversion or redemption by you until twelve (12) months after the date of your first Net Purchase (“Initial Period”). After your Initial Period, Points may be

converted and redeemed from Points to the following uses, at any time, subject to the limitations described herein (“Redemption Event”):

• Cashback

• Divvy Travel powered by TripActions

• Statement credit

• Tango Gift cards

You may complete a Redemption Event by visiting getdivvy.com/rewards and completing the required steps to convert and redeem Points. Payment for any cashback conversion and redemption

of Points shall be made to you within ten (10) business days of a Redemption Event. Conversion and redemption of Points for travel rewards for use with TripActions shall occur within ten (10)

business days. Application of a statement credit shall occur within ten (10) business days. Conversion and redemption of Points for Tango Gift Cards shall occur within ten (10) business days.

Visit getdivvy.com/rewards to access the Divvy Rewards Calculator for additional information regarding how your Points will convert into the above rewards categories, which conversion

process and rates are subject to change at any time, in Divvy’s sole and absolute discretion.

4. Promotional Rewards: Divvy may allow you to (i) accrue promotional Points, which are described as an increase in the rate at which you may accrue Points over the ordinary rate in which

you would otherwise accrue points absent the promotional feature (“Promotional Points”) or (ii) or earn alternative cashback (“Alternative Cashback”)(together, “Promotional Rewards”). Any

Promotional Rewards will be determined on a case-by-case basis. Promotional Rewards may be subject to you (i) meeting an agreed-upon spending target during the promotional period, (ii)

selecting a specific Billing Cycle during the promotional period, (iii) executing the ACH Authorization Agreement (Enrollment in Auto-Pay Program) during the promotional period or (iv)

complying with any other requirements outlined in writing between the parties. Unless otherwise agreed upon in writing, Divvy may rescind the Promotional Rewards at any time in Divvy’s sole

discretion and without notice to you. Divvy must notify you of the details of any applicable Promotional Rewards in writing, which you must agree to in writing, before you may earn any

Promotional Rewards. If you fail to meet the eligibility requirements for Promotional Rewards during the promotional period as outlined in writing, you may not be eligible for any Promotional

Rewards during the promotional period.

5. Effect of Billing Cycle Selection: You have the option to select a billing cycle, which is the periodicity of sweeping the accounts (“Billing Cycle”). Billing cycle options include (i) Weekly,

(ii) Bi-monthly or (iii) Monthly. Any other billing cycle option will be treated as Weekly. Your selection of Billing Cycle will dictate that structure under which you will accrue Points, as

outlined in the Divvy Rewards Table, subject to the terms and restrictions found herein. The “Payment Due Date” reflected on your billing statement may also vary based on your Billing Cycle

selection.

6. Cross Border and Foreign Currency Transaction Fees: Cross Border and Foreign Currency Transaction Fees shall not be considered Net Purchases when calculating Points, and therefore,

no Points may be accrued on Cross Border and Foreign Currency Transaction Fees.

7. Points and Early Termination: All accrued Points will be forfeited and will not be available for conversion or redemption if you (i) are no longer a customer of Divvy at the end of the Initial

Period or (ii) have spent less than Five Thousand Dollars ($5,000) in each of the last three (3) months of the Initial Period, regardless of your total Net Purchases during the Initial Period.

8. Points and Other Restrictions:

• You must spend at least thirty percent (30%) of you credit line during any month to qualify for Divvy Rewards. You will not accrue any Points on Net Purchases as described herein

during any month in which you do not spend at least thirty percent (30%) of your credit line. In the event you have redeemed Points early in given month, but by the end of that

same month have not spent at least thirty percent (30%) of you credit line, Divvy will revoke all Points earned in that month.

• Net Purchases with Plastiq are not eligible to accrue any Points.

• Regardless of your selected Billing Cycle, monthly Points earned in the “restaurants, hotels and on recurring software subscriptions” categories shall be earned at the respective

multipliers found in the Divvy Rewards Table, up to an aggregate of Five Thousand Dollars ($5,000) in Net Purchases in all categories combined. After such Five Thousand Dollar

($5,000) Net Purchases cap is reached, all additional Net Purchases completed for the remainder of that given month, regardless of category, shall accrue Points at the “on everything

else” multiplier associated with your selected Billing Cycle. For example, if you complete Three Thousand Dollars ($3,000) in Net Purchases at qualifying restaurants, One Thousand

Dollars ($1,000) in Net Purchases at qualifying hotels, and One Thousand Dollars ($1,000) in Net Purchases on qualifying software subscriptions during a given month, all other

J&S Version

Net Purchases made for the remainder of that given month, regardless of category, shall accrue Points at the “on everything else” multiplier associated with your selected Billing

Cycle.

• If you have zero (0) Net Purchases in any given month, you forfeit all accrued Points.

• If you are (i) delinquent on your account or (ii) in default at any time, you forfeit all accrued Points.

9. Credit Underwriting Models: You may have credit underwritten through one of several available models of Cross River Bank which may include, but are not limited to, unsecured credit,

guarantees, letters of credit, surety bonds, or other acceptable forms of security in order for you to receive credit. Relying on such security may result in reduced or no eligibility for Points, as

reflected in the approval communication provided to you.

10. Qualifying MCC, NAICS and SIC Codes and Points: Only Net Purchases made with the following MCC, NAICS and SIC codes shall be eligible for Points accrual as specifically described

in the Divvy Rewards Table.

• Restaurants MCC Codes: 5462, 5811, 5812, 5813

• Hotels MCC Codes: 3500-3999

• Recurring Software and Subscriptions:

o NAICS Codes: 511210 Software Publishers, 5191 Other Information Services

o SIC Code: 5968: Direct Marketing, Continuity/Subscription Merchant

All other Net Purchases, regardless of category, which fall outside of the above described MCC, NAICS or SIC codes, shall only be eligible for Points accrual at the “on everything else” multiplier

associated with your selected Billing Cycle.

11. Divvy Solely Responsible: Divvy is solely responsible for administration of the Divvy Rewards program described herein and the payment of all amounts or benefits due to you under this

section. Cross River Bank is not a party to this Rewards Agreement and this Rewards Agreement does not affect, modify, or amend the Account Application and the terms and conditions of

your agreement with Cross River Bank. You agree to look exclusively to Divvy in the event of any dispute arising out of or relating to the Divvy Rewards program described herein or the amounts

paid or payable to you hereunder.

12. Miscellaneous Provisions:

• Default: If you default under the terms of the Divvy Business Charge Card Agreement, you lose all accrued Points or Promotional Rewards, including the ability to complete a

Redemption Event with any accrued Points or Promotional Rewards.

• Severability: Whenever possible, each portion of this Rewards Agreement will be interpreted in such a manner as to be effective and valid under applicable law, but if any portion

of this Rewards Agreement is held to be prohibited by or invalid under applicable law, such portion will be deemed restated to reflect the original intentions of the parties as nearly

as possible in accordance with applicable law, and, if capable of substantial performance, the remaining portions of this Rewards Agreement will be enforced as if this Rewards

Agreement was entered into without the invalid portion.

• Assignment: You may not assign this Rewards Agreement to any other entity without the express prior written consent of Divvy or its successor in interest, as applicable. Divvy

may, in its sole discretion, assign this Rewards Agreement and its obligations, transfer any right or delegate any duty of performance under this Rewards Agreement without further

notice. The person or entity(ies) to whom Divvy makes any such assignment is entitled to all of Divvy’s rights under this Rewards Agreement, to the extent that those rights were

assigned.

• Modification; Waiver: We may change the terms of this Rewards Agreement from time to time, which may include adding, modifying or deleting any term to this Rewards

Agreement. If required by law, we will give you advance written notice of the change(s). No delay or omission by either Party to exercise any right or power hereunder will impair

such right or power or be construed to be a waiver thereof. A waiver by either Party of any of the obligations to be performed by the other or any breach thereof will not be construed

to be a waiver of any succeeding breach thereof or of any other obligations herein contained.

• Governing Law and Venue: The laws of the State of Utah, without reference to any conflict of law provisions or decisions, shall govern all questions concerning the construction,

validity and interpretation of this Agreement and the performance of the obligations imposed by this Agreement. The exclusive venue for any dispute relating to this Agreement

shall be in the state courts located in Utah or the federal courts located in the District of Utah.

• Term and Termination: This Rewards Agreement shall remain in effect until terminated upon delivery of written notice of termination by either party, which written notice may

be delivered at any time. Notice of termination shall in no way affect Company's obligation to pay any amounts owed under the Account Application.

The signatory below acknowledges and certifies that he or she is a proprietor, general partner or officer of you with authority to enter into this Rewards Agreement on behalf of

Company (“Authorized Representative”).

Company:

Authorized Representative:

Print Name:

Title:

Date:

OMB Control Number 1506-0070

31 CFR § 1010.230 CERTIFICATION REGARDING

BENEFICIAL OWNERS OF LEGAL ENTITY CUSTOMERS

I. GENERALINSTRUCTIONS

This is an optional form provided for your convenience. The required information may be provided in other formats. When

completed, this form is provided to the financial institution where the account is opened. DO NOT SEND TO FinCEN.

Where may I obtain a copy of the form?

A copy (pdf) may be downloaded from the FinCEN website at www.fincen.gov under the “Filing Information” tab. The form may

be completed on a computer using the free Adobe Reader software.

What is this form?

To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify, and

record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise

involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring

the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement

investigate and prosecute these crimes.

Who has to complete this form?

This form must be completed by any person opening a new account on behalf of a legal entity with any of the following U.S.

financial institutions: (i) a bank or credit union; (ii) a broker or dealer in securities; (iii) a mutual fund; (iv) a futures

commission merchant; and (v) an introducing broker in commodities.

For the purposes of this form, a legal entity includes a corporation, limited liability company, or other entity that is created by

a filing of a public document with a Secretary of State or similar office, a general partnership, and any similar business entity

formed in the United States or a foreign country. Legal entity does not include sole proprietorships, unincorporated associa-

tions, or natural persons opening accounts on their own behalf.

What information do Ihave to provide?

When you open a new account on behalf of a legal entity, the financial institution will ask for information about the legal

entity’s beneficial owner(s), including their name, address, date of birth and social security number (or passport number or

other similar information, in the case of Non-U.S. persons). The financial institution may also ask to see a copy of a

driver’s license or other identifying document for each beneficial owner listed on this form.

Beneficial owners are:

(1) Each individual, if any, who owns, directly or indirectly, 25 percent or more of the equity interests of

the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a

corporation; and

(2)An individual with significant responsibility for managing the legal entity customer (e.g., a Chief

Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner,

President, Vice President, or Treasurer).

The number of individuals that satisfy this definition of “beneficial owner” may vary. Under section (1), depending on the

factual circumstances, up to four individuals (but as few as zero) may need to be identified. Regardless of the number of

individuals identified under section (1), you must provide the identifying information of one individual under section (2). It is

possible that in some circumstances the same individual might be identified under both sections (e.g., the President of Acme,

Inc. who also holds a 30% equity interest). Thus, a completed form will contain the identifying information of at least one

individual (under section (2)), and up to five individuals (i.e., one individual under section (2) and four 25 percent equity

holders under section (1))

a legal entity may have multiple “beneficial owners,” this form requires you to list only those that own 25% or more (up

to five) under each of the two prongs of the definition above. If appropriate, the same individuals may be listed under

both prongs.

Rev. 6.6 Aug. 2017

CERTIFICATION OF BENEFICIAL OWNER(S)

The information contained in this Certification is sought pursuant to Section 1020.230

of Title 31 of the United States Code of Federal Regulations (31 CFR 1020.230).

All persons opening an account on behalf of a legal entity must provide the following information:

1. Last Name and title of Natural Person Opening Account

2. First Name

3. Middle Initial

4. Name and type of Legal Entity for Which the Account is Being Opened

4a. Legal Entity Address

4b. City

4c. State

4d. ZIP/Postal Code

SECTION I

(To add additional individuals, see page 3)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract

arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed

above.

Check here if no individual meets this definition and complete Section II.

5. Last Name 6. First Name 7. M.I.

8. Date of birth

(MM/DD/YYYY)

9. Address 10. City

11. State

12. ZIP/Postal Code

13. Country

14. SSN (U.S. Persons)

15. For Non-U.S. persons

(SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number

and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar

safeguard.

SECTION II

Please provide the following information for an individual with significant responsibility for managing or directing the

entity, including, an executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief

Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer); or Any other individual

who regularly performs similar functions.

16. Last Name 17. First Name 18. M.I.

19. Date of birth

(MM/DD/YYYY)

20. Address 21. City

22. State

23. ZIP/Postal Code

24. Country 25. SSN (U.S. Persons)

26. For Non-U.S. persons

(SSN, Passport Number or other similar identification number)

26a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number

and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar

safeguard.

I, __________________________ (name of person opening account), hereby certify, to the best of my

knowledge, that the information provided above is complete and correct.

Signature:

Date:

(MM/DD/YYYY)

Legal Entity Identifier (Optional)

Rev. 6.7 Sept., 2017

Additional Section 1 - Second Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract

arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed

above.

5. Last Name 6. First Name 7. M.I.

8. Date of birth

(MM/DD/YYYY)

9. Address 10. City

11. State

12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons)

15. For Non-U.S. persons (SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number

and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar

safeguard.

Additional Section 1 - Third Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract

arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed

above.

5. Last Name 6. First Name 7. M.I.

8. Date of birth

(MM/DD/YYYY)

9. Address 10. City

11. State

12. ZIP/Postal Code

13. Country

14. SSN (U.S. Persons)

15. For Non-U.S.persons

(SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Additional Section 1 - Fourth Beneficial Owner (If required)

Please provide the following information for an individual(s), if any, who, directly or indirectly, through any contract

arrangement, understanding, relationship, or otherwise owns 25% or more of the equity interests of the legal entity listed

above.

5. Last Name 6. First Name 7. M.I.

8. Date of birth

(MM/DD/YYYY)

9. Address 10. City

11. State

12. ZIP/Postal Code

13. Country 14. SSN (U.S. Persons)

15. For Non-U.S. persons

(SSN, Passport Number or other similar identification number)

15a. Country of issuance:

Note: In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number

and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar

safeguard.

Paperwork Reduction Act Notice

Public recordkeeping burden for this collection of information is estimated to average 30 minutes per response, including the time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information

unless it displays a valid OMB control number. The OMB control number for this information collection is 1506-0070. You may submit

comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,

by calling the FinCEN Resource Center at 800-767-2825 or by email at frc@fincen.gov. Alternatively, you may mail us comments at Policy

Division, Financial Crimes Enforcement Network, P.O. Box 39, Vienna, VA 22183. Please include 1506–0070 in the body of the text.

Rev. 6.7 Sept., 2017

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Account Application Please read the following information before

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Account Application Please read the following information before Form

Related forms

Fillable Account Application Please read the following information before

Fill Online, Printable, Fillable, Blank Account Application Please read the following information before Form

Related forms

First 20 documents completely FREE!