Fillable DDA/DBACHANGEFORM STEP1:CHANGE INFORMATION (Required) Pleasecheckallchan esthata l andcom

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DDA/DBACHANGEFORM STEP1:CHANGE INFORMATION (Required) Pleasecheckallchan esthata l andcom

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Version7‐18
Thankyoufornotifyingusoftherecentchangetoyourbusiness.WearehappytoprocesstheDDA/DBAchangeyourequested
foryourpaymentprocessingaccount.Theinformationbelowwillhelpguideyouthroughthesteps,sothatwecanprocessyour
request.
DBAand/orLegalBusinessName,(Complete‐Sections1,2,3,5,7&9)
DDA,(Complete‐Sections1,2,8&9)
AddorRemoveanAuthorizedSigner,(Complete‐Sections1,2,5,6,&9)
Helpfulinformationforcompletingeachsection:
BUSINESSINFORMATION–
THEENTIRESECTIONMUSTBECOMPLETED
.
TAXINFORMATION(SubstitutefromW‐9)–
FordetailedinstructionsoncompletingtheW‐9Form,pleaserefertoyourtaxreturnorvisit
www.irsgov/pub/irs‐pdf/iw9.pdf.Thisinformationisthesameastheinformationusedtofiletaxesforyourbusiness.It’simportantthat
thisinformationbecorrectasitwillbeusedfortherequiredIRS1099Kreporting.
DBANAMECHANGE–EnterthenewDBAand/orLegalBusinessNameandaddressinformation.
OTHERADDRESS–PleasecompleteifMailing,Billing,ChargebackorCopyRequestisdifferentthanDBA/LegalBusinessAddress.
PRINCIPALINFORMATION–Includeallownerswith25%orgreaterownership.IftherearenonethenprovidetheinformationoftheAuthorized
Signerofthebusiness.AtleastonepersonshouldbeidentifiedastheResponsibleParty.TheResponsiblePartymustbeaBeneficialOwneror
theAuthorizedSignerwithday‐to‐daycontroloftheBusiness.
REMOVECURRENTOWNER/AUTHORIZEDSIGNER–CompletethissectionifyouareremovingaCurrentOwnerorAuthorizedSigner.
INTERMEDIARYBUSINESS/OWNER–Completeif
therearebusinessand/orbusinessownerswith25%orgreaterownership
DDACHECKINGACCOUNTCHANGE–PleaseprovidecurrentcompleteDDAinformation(fullroutingandaccountnumbers)fortheaccount
typethatischanging,(deposit,billing,chargeback,Fusebox)aswellasnewcompleteDDAinformation(fullroutingandaccountnumbers)
.

Botharerequiredinordertomakeanupdate.Ifyourbankinginformationisnotchanging,thissectionisnotrequired.
SIGNATUREINFORMATION–MustbesignedbytheprincipalorauthorizedsignerlistedinSection5.Ifprincipalhaschanged,
theprevious
principaldoesnotsign.Ifaddingadditionalprincipalsorauthorizedsigners,thecurrentprincipalorauthorizedsignermustsign.Account
Certifier:couldbeaBeneficialOwner,AuthorizedSignerorResponsiblePartywhowillcertifytheaccountinformationiscorrect.Atleastone
personshouldbeidentified(Requiredonlyifaddingorchangingownership)
Forquestionsregardingsections1‐9pleasecontactusat1‐800‐725‐1243.

HoursofOperationare8:00am‐4:00pmEasternMonday‐Friday.
Pleasereturnthecompletedsections1–9backtoMerchant.Change@elavon.com
•
Oncewereceiveyourcompletedform,wewillreviewforanymissinginformation.Wemaycontactyouifadditionalinformationis
required.
•
Ifadditionalinformationisnotprovidedwithin8businessdays,therequestwillbecancelled.
•
Anemailnotificationwillbesentprovidingthestatusofyourrequest.
STEP1:CHANGE INFORMATION (Required)
Pleasecheckallchan
g
esthata
pp
l
y,
andcom
p
letethesectionsindicated.
STEP2:W er ev i e w y o u r r e q u e s t .
DDA/DBACHANGEFORM
Ver 1.7.5.22.2019.MFM.1886
Version7‐18
BUSINESSINFORMATION
MerchantIdentificationNumber(MID):

DBAName(Current):
EffectiveDateofChange:

DBAPhone#:

ContactName: DBAFax#: MobilePhone#:
DBAAddress1(NoPOBox): DBAAddressType:
Type:

Businessor

Residential
DBAAddress2(NoPOBox):
EmailAddress:

City:State:ZipCode:
BusinessCountryofFormation(Headquartered):

CountryofPrimaryBusinessOperations:
AnnualRevenue:

EvidenceofLegalStatus:
Isyourbusinesspartofafinancialinstitution?
IsyourbusinessaU.S.,State,orLocalgovernmententity?
Isyourbusinesspartofapubliclytradedentity?Ifsowhatisyourtickersymbol?
Isyourbusinesspartofasubsidiaryofapubliclytradedcompany?Ifsowhatisyourtickersymbol?
Isyourbusinessaregisterednon‐profit?
TAXINFORMATION–(
THISSECTIONMUSTBECOMPLETEDFORALLUPDATES)
BusinessType:
Sole Proprietor
PublicCorp.
CloselyHeldCorp.
Sub SCorp. Professional Corporation
Limited
Partnership
Government
Tax Exempt Organization Other(Assn/Estate/Trust)
LimitedLiabilityCompany–TaxClassification(D=Disregardedentity,C=Corporation,S=SCorporation,P=Partnership)

IfLLC,pleaseindicateifD,C,SorP

LegalBusinessName(Asshownonyourbusinessincometaxreturns.ForSoleProprietors,thisshouldalwaysbetheowner’sname)

AddressType:
Businessor

Residential
SocialSecurity#/TIN#
or
EIN(EmployerIdentification#):

LegalBusinessAddress(POBoxnotallowed):

City:

State:

ZipCode:

DBANAMECHANGE
DBABusinessName(New):
DBAAddress1(NoPOBox):

DBAAddress2(NoPOBox):

DBAAddressType:
Type:

Businessor

Residential
City:

State:

ZipCode:

Ver 1.7.5.22.2019.MFM.1886
Version7‐18
OTHERADDRESS(
PleasecompleteifMailing,Billing,ChargebackorCopyRequestisdifferentthanDBAAddress.)
M
AILING
B
ILLING
C
HARGEBACK
C
OPY
R
EQUEST
LocationName:

PhoneNumber:
ContactName:
FaxNumber:
Address:

City:

State:

ZipCode:

PRINCIPAL INFORMATION‐
Includeallownerswith25%orgreaterownership.IftherearenonethenprovidetheinformationoftheAuthorized
Signerofthebusiness.OnepersonshouldbeidentifiedastheResponsibleParty.TheResponsiblePartymustbeaBeneficialOwnerorthe
AuthorizedSignerwithday‐to‐daycontroloftheBusiness.
PRINCIPAL1INFORMATION‐SECTION
 BeneficialOwner:PercentageofOwnership

% AuthorizedSigner ResponsibleParty SoleProprietor
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)

AddressType:
Business

Residentialor
Military PhoneNumber:

City: State/Province:ZipCode: Country:
PreviousAddress(iflessthan2yearsinHomeAddress)
HomeAddress:(NoP.O.Box)City:State:ZipCode:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN#:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
PRINCIPAL2INFORMATION‐SECTION
 BeneficialOwner:PercentageofOwnership

% AuthorizedSigner ResponsibleParty SoleProprietor
FirstName: MiddleName:LastName:Title:
Address:(NoP.O.Box)

AddressType:
Business

Residentialor
Military
PhoneNumber:

City: State/Province:ZipCode: Country:
PreviousAddress(iflessthan2yearsinHomeAddress)
HomeAddress:(NoP.O.Box)City:State:ZipCode:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
Ver 1.7.5.22.2019.MFM.1886
Version7‐18
REMOVECURRENTOWNER/AUTHORIZEDSIGNER–Completeonlyifchanging
PRINCIPAL3INFORMATION‐SECTION
 BeneficialOwner:PercentageofOwnership

% AuthorizedSigner ResponsibleParty SoleProprietor
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)

AddressType:
Business

Residentialor
Military
PhoneNumber:

City: State/Province:ZipCode: Country:
PreviousAddress(iflessthan2yearsinHomeAddress)
HomeAddress:(NoP.O.Box)City:State:ZipCode:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
PRINCIPAL4INFORMATION‐SECTION
 BeneficialOwner:PercentageofOwnership

% AuthorizedSigner ResponsibleParty SoleProprietor
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)

AddressType:
Business

Residentialor
Military
PhoneNumber:

City: State/Province:ZipCode: Country:
PreviousAddress(iflessthan2yearsinHomeAddress)
HomeAddress:(NoP.O.Box)City:State:ZipCode:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
FirstName: MiddleName:LastName:
FirstName: MiddleName:LastName:
Ver 1.7.5.22.2019.MFM.1886
Version7‐18
INTERMEDIARYBUSINESS/OWNER
Doesthebusinesshaveotherinvestors(businesses)whohavea25%orgreaterownershipstake? Yes(Ifyes,completesection7) No
(Includealladditionalintermediarieswith25%orgreaterownership)
ADDITIONALINTERMEDIARYBUSINESS/OWNER
(Includealladditionalintermediarieswith25%orgreaterownership)
INTERMEDIARYBUSINESS/OWNER1INFORMATION‐SECTION
IntermediaryBusinessName: IntermediaryBusinessContactName: PercentageofOwnership:%
IntermediaryBusinessPhoneNumber:  IntermediaryEmailAddress(optional):
Address:(NoP.O.Box)
AddressType:
Businessor

Residential
City:
State/Province:ZipCode: Country:
INTERMEDIARYBUSINESSOWNER‐SECTION
IntermediaryBusinessOwner Yes No PercentageofOwnership:%
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)
AddressType:
Business

Residentialor
Military PhoneNumber:

City: State/Province:ZipCode: Country:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
Signature: Date:
INTERMEDIARYBUSINESS/OWNER2INFORMATION‐SECTION
IntermediaryBusinessName: IntermediaryBusinessContactName: PercentageofOwnership:%
IntermediaryBusinessPhoneNumber:  IntermediaryEmailAddress(optional):
Address:(NoP.O.Box)
AddressType:
Businessor

Residential
City:
State/Province:ZipCode: Country:
INTERMEDIARYBUSINESSOWNER‐SECTION
IntermediaryBusinessOwner Yes No PercentageofOwnership:%
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)
AddressType:
Business

Residentialor
Military PhoneNumber:

City: State/Province:ZipCode: Country:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate: ExpiryDate:
Signature: Date:
Ver 1.7.5.22.2019.MFM.1886
Version7‐18
ADDITIONALINTERMEDIARYBUSINESS/OWNER
(Includealladditionalintermediarieswith25%orgreaterownership)
ADDITIONALINTERMEDIARYBUSINESS/OWNER
(Includealladditionalintermediarieswith25%orgreaterownership)
INTERMEDIARYBUSINESSOWNER3INFORMATION‐SECTION
IntermediaryBusinessName: IntermediaryBusinessContactName: PercentageofOwnership:%
IntermediaryBusinessPhoneNumber:  IntermediaryEmailAddress(optional):
Address:(NoP.O.Box)
AddressType:
Businessor

Residential
City:
State/Province:ZipCode: Country:
INTERMEDIARYBUSINESSOWNER‐SECTION
IntermediaryBusinessOwner Yes No PercentageofOwnership:%
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)
AddressType:
Business

Residentialor
Military PhoneNumber:

City: State/Province:ZipCode: Country:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate:ExpiryDate:
Signature: Date:
INTERMEDIARYBUSINESSOWNER4INFORMATION‐SECTION
IntermediaryBusinessName: IntermediaryBusinessContactName: PercentageofOwnership:%
IntermediaryBusinessPhoneNumber:  IntermediaryEmailAddress(optional):
Address:(NoP.O.Box)
AddressType:
Businessor

Residential
City:
State/Province:ZipCode: Country:
INTERMEDIARYBUSINESSOWNER‐SECTION
IntermediaryBusinessOwner Yes No PercentageofOwnership:%
FirstName: MiddleName:LastName: Title:
Address:(NoP.O.Box)
AddressType:
Business

Residentialor
Military PhoneNumber:

City: State/Province:ZipCode: Country:
IDType: SocialSecurity#/ SocialInsurance#/ ITIN:
Other:ID#:
DateOfBirth: USPerson?
Yes No
Foreign–IDType: IfGov’tIssued–IDName: IfForeignID–CountryOfIssuance:
IdentificationDocument: IssuingCountry(IfApplicable): IssuingState(IfApplicable):
Document#: IssuingDate:ExpiryDate:
Signature: Date:
Ver 1.7.5.22.2019.MFM.1886
Version7‐18
DDACHECKINGACCOUNTCHANGE
CurrentAccountInformationfortheAccountTypethatischanging(RequiredforVerification)
CurrentDe
p
ositAccount
ABA/Routing
Number
        
DDAAccountNumber



Current
BillingAccount CheckhereifsameasDepositAccount
ABA/Routing
Number:
        
DDAAccountNumber:



CurrentChargebackAccount CheckhereifsameasDepositAccount
ABA/Routing
Number:
        
DDAAccountNumber:

IfyoualsoprocessthroughFuseboxandwouldliketoupdateyourbankaccountinformationontheGatewaypleasecompletetheinformationbelow.ThisinformationisforthebillingofElavon
HostedPaymentFuseboxGatewayservicefeesonly.IfyoudonotuseElavonasyourProcessor/Acquirer,youwillneedtonotifytheappropriatepartiessothechangesaremadetotheirsystem
aswell.


CurrentFuseboxBillingAccount CheckhereifsameasDepositAccount
SiteID:

ABA/Routing
Number:
        
DDAAccountNumber:

DEBIT/CREDITAUTHORIZATIONANDPAYMENTAGREEMENT:MERCHANTHEREBYAUTHORIZESELAVON,INACCORDANCEWITHTHEMERCHANTPROCESSING
AGREEMENT(THETERMSOF
ELAVON’SCURRENTTERMSOFSERVICEANDMERCHANTOPERATINGGUIDEBEINGEXPRESSLYINCORPORATEDHEREINANDAGREEDTOBY
MERCHANT),TOINITIATEDEBIT/CREDITENTRIES
TOMERCHANT’SBUSINESSCHECKINGACCOUNTASINDICATED.THEAUTHORITYISTOREMAININFULLFORCEAND EFFECTUNTIL(A)ELAVONHASRECEIVEDWRITTENNOTIFICATIONFROM
MERCHANTOFITSTERMINATIONINSUCHMANNERASTOAFFORDELAVONREASONABLE
OPPORTUNITYTOACTONIT;AND(B)ALLOBLIGATIONSOFMERCHANTTOELAVONTHATHAVE
ARISENHAVEBEENPAIDINFULL,INCLUDING,BUTNOTLIMITEDTO,
THOSEOBLIGATIONSDESCRIBEDINTHEMERCHANTPROCESSINGAGREEMENT.THISAUTHORIZATIONEXTENDSTO
SUCHENTRIESINSAIDACCOUNTCONCERNING
L E A S E , R E N T A L , O R P U R C H A S E A G R E E M E N T S F O R P O S T E R M I N A L A N D / O R A CCOMPANYINGEQUIPMENT.
NOTE:IfyoureceivefundingdirectlyfromAmericanExpress(800‐528‐5200),Discover(800‐347‐2000)and/orDinersClub(800‐525‐7376),youwillneedtonotifythemofyour change,aseachwillneed
tomaketheappropriatechangestotheirsystemaswell.
NewAccountInformation
NewDe
p
ositAccount
ABA/Routing
Number
        
DDAAccountNumber



NewBillingAccount CheckhereifsameasDepositAccount
ABA/Routing
Number:
        
DDAAccountNumber:



NewChargebackAccount CheckhereifsameasDepositAccount
ABA/Routing
Number:
        
DDAAccountNumber:

IfyoualsoprocessthroughFuseboxandwouldliketoupdateyourbankaccountinformationontheGatewaypleasecompletetheinformationbelow.ThisinformationisforthebillingofElavon
HostedPaymentFuseboxGatewayservicefeesonly.IfyoudonotuseElavonasyourProcessor/Acquirer,youwillneedtonotifytheappropriatepartiessothechangesaremadetotheirsystem
aswell.


NewFuseboxBillingAccount CheckhereifsameasDepositAccount
SiteID:

ABA/Routing
Number:
        
DDAAccountNumber:

Ver 1.7.5.22.2019.MFM.1886
Version7‐18
SIGNATUREINFORMATION
Bysigningthisdocument,youareagreeingonbehalfoftheCompanytoamandatory bindingarbitrationprovisionsetforthintheTOSand
expresslyincorporatedherein.“TheInternalRevenueServicedoesnotrequireyourconsenttoanyprovisionofthisdocumentotherthan
thecertificationsrequiredtoavoidbackupwithholding.Inaddition,bysigningthiscompanyapplication,youherebycertifythattothebest
ofyourknowledge,theinformationprovidedaboutyou,thenameandaddressprovidedforthelegalentitycustomer,andtheinformation
providedaboutthebeneficialowner(s)and/ortheindividualwithcontroloverthelegalentitycustomeriscompleteandaccurate.Please
NotifyElavoniftherearechangesinyourbeneficialownershipstructureorifyourcompanyhastheabilitytoissuebearershares.
Owner/OfficerSignature X PrintedName Title Date
Owner/OfficerSignature X PrintedName Title Date
For BANK/INTERNAL USE ONLY
Rel PendReason Approved Keyed Validated
Ver 1.7.5.22.2019.MFM.1886
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DDADBACHANGEFORM STEP1:CHANGE INFORMATION (Required) Pleasecheckallchan esthata l andcom

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Completed 19 October 2021

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