<p> Information Profile for State of Florida Agencies Credit Card/Electronic Transaction Processing (Form may be submitted by Email to address shown below) This form must be completed for each individual location 1. AGENCY NAME: 8. LOCATION NAME: 2. AGENCY ADDRESS: 9. LOCATION ADDRESS: 3. AGENCY CITY: 10. LOCATION CITY: 4. AGENCY CONTACT: 11. LOCATION CONTACT: 5. AGENCY TELEPHONE: 12. LOCATION TELEPHONE: 6. AGENCY EMAIL: 13. LOCATION EMAIL: 7. AGENCY FAX: 14. LOCATION FAX: 15. E-SERVICE DESCRIPTION: (Identity of statute, fees, and general program service)</p><p>16. DATE SUBMITTED: 17. EXPECTED “LIVE” DATE: 18. TRANSACTION TYPE ACCEPTED: MasterCard______Visa_____American Express_____Discover_____Diners_____JCB_____DEBIT_____Electronic Checks_____ POS Conversion_____ 19. PROCESSING TYPE: (Check the type of system currently used or planned) Internet_____POS Terminals_____Electronic Cash Register_____IVR_____Other_____ 20. ESTIMATED ANNUAL CREDIT CARD VOLUME: Annual Amount: Average Transaction: 21. ESTIMATED ELECTRONIC CHECK VOLUME: Annual Amount: Average Transaction: 22. NEW ACCOUNT: 23. EXISTING MERCHANT NBR: 24. SETTLEMENT INFORMATION: Bank: Routing Number: Account Number: 25. CHARGEBACK INFORMATION: Bank: Account Number: Routing Number: Mail Chargebacks to: City: Zip: 26. PAYMENT OF FEES: Invoice Address: Debit Account Number: 27. ACCEPTANCE: Describe agency’s payment acceptance requirements, also describe hardware, software, integration, and interface requirements, including any special configuration, implementation/conversion needs. For POS terminals, will you be using owned equipment (include vendor or type), or will you need equipment? Are communication lines currently installed? Explain the agency’s use of merchant numbers. Does this location require a separate merchant number? (attach additional sheet if necessary)</p><p>28. RECONCILIATION: Define transaction identification scheme and reconciliation needs by identifying the following. How is the transaction defined, i.e. invoice number, license number, etc. Identify correlating general ledger information related to the transaction scheme. FOR EXAMPLE: Transaction ID: DBPR-H04-000-2000-2001 indicates Real Estate Renewal using the following GL information: 790989998/fund898/etc. How many data capture fields do you need to capture and update GL and application? (attach additional sheet if necessary)</p><p>29. APPROVED BY STATE TREASURY 30. REVIEWED BY STATE TECHNOLOGY OFFICE (For State Agencies and Judicial Branch Only) By: Date: By: Date:</p><p>31. CONTACTS FOR PROCESSING AND ASSISTANCE IN PREPARATION OF THIS FORM State Agencies and Judicial Branches Mail, Fax, or Email to: Terry Straub Telephone: (850) 413-2783 Department of Financial Services Fax: (850) 488-0699 200 East Gaines Street Email: [email protected] Tallahassee, FL 32399-0344 Units of Local Government Mail, Fax, or Email directly to: Andrea Morris Telephone: (850) 561-1774 Bank of America Fax: (850) 561-0688 Commercial Card Services Email: [email protected] 315 South Calhoun Street Tallahassee, FL 32301</p>