Merchants

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Merchant ID

Legal Name

DBA Name

Processor

Agent

Split

Is Override

Password

Received Date

Approved Date

Activation Date

Closed Date

Product Type

Status

Address

Address 2

City

ZIP

Country

State

Contact

Email(comma separated)

Phone

Phone 2

Cell

Fax

URL

DBA Same as Legal Address

Address

City

ZIP

Country

State

Mailing Address Same as DBA

Address

City

ZIP

Country

State

File here *	Download	Notes *	Status	Date

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Bank 1 Information

Bank Name

Account Name

Rounting Number

Account Number

Billing Type

Gross Settlement

Net Settlement

Bank 2 Information

Bank Name

Account Name

Rounting Number

Account Number

Overrides who receive partial commission on all of Palacios 3-G LLC Accounts

Default Setup

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Processor wise Setup

Select Processor *

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Select Processor *

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Merchant *

Month *

Year *

Merchant CMS

EIN/Federal Tax ID Type

MCC Code

EIN/Federal Tax ID #

Type of Legal Entity

State incorporated in

Types of Goods Sold

Primary Transaction Type

Internet

%

Swipe

%

Keyed

%

Average Ticket

Telephone Order

%

Annual Volume

Business Start Date

High Ticket

Persoanl Guarantor

Monthly Volume

Discount Method

Refund Policy

30 Days

60 Days

Other

None

Date

Reminder Date & Time

Employee

Notes

Sr. No.	Date	Reminder Date	Employee	Note	Action
1	Aug 01 2023			User: Pennye McAnulty -> Notes: TT Jessica receiving comm errors. Conferenced in with buypass.
2	Aug 01 2023			User: Pennye McAnulty -> Notes: They received the new terminal and it is not working on dial. Rise stated that they need to be on IP that the newer terminals will not work well on dial.
3	Aug 01 2023			User: Pennye McAnulty -> Changed : MonthlyVolume FROM 0.00 TO 13000.00
4	Aug 01 2023			User: Pennye McAnulty -> Changed : AnnualVolume FROM 0 TO 130000.00
5	Aug 01 2023			User: Pennye McAnulty -> Changed : AverageTicket FROM 0.00 TO 250.00
6	Aug 01 2023		Morgan Withee	User: Morgan Withee -> Notes: Old MID: 520001676440
7	Aug 01 2023			User: Pennye McAnulty -> Notes: TT Jessica terminal receiving comm error.
8	Aug 01 2023			User: Pennye McAnulty -> Notes: If terminal has issues please call Heartland @ 866-349-6591. The Tid id MRFK034001
9	Aug 01 2023			User: Pennye McAnulty -> Notes: TT Jessica terminal getting error messages. conferenced in Vantiv
10	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Pin Pad Peggy purchased had no XPI download in it. She is having the pin pad swapped through TASQ.
11	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: TT Jessica, getting Merchant ID error 1. NPC having network errors, no time frame for fix. They are working on the issue.
12	Aug 01 2023			User: Christina Sullins -> Notes: TT Paul with the GEM Team. Voyager should be ready if the service request has been closed. Emailed Peggy to let her know.
13	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Download went through after removing Paymentech certificates, WEX on hold pending a W9. Chris faxed W9 to merchant per Peggy.

Application Type

Discount

Business Type

MCC Code

Visa/MC/Discover Rate Category

Base/Qualified (%)

Mid Qualified (%)

Non Qualified (%)

Base Debit- Non Pin Debit(Sig Debit Rate) (%)

Rewards Discount (%)

Statement Fee

Card On File Fee

PCI Fee

Non PCI Compliance

Authorization Fee

Per Item Fee

EBT Fee

FNS/EBT Number

Pin Debit Item Fee

Pin Debit Discount

Amex Opt Blue Rate

Base/Qualified Rate (%)

Mid Qualified Rate (%)

Non Qualified Rate (%)

Program Cost Opt Blue (%)

Authorization Fee

Per Item Fee

Other Monthly Fee

Ancillary Fees

Batch Fee

Retrievel Fee

Chargeback Fee

ACH Change Fee

Voice Auth Fee

Gateway Monthly Fee

Setup Fee

Owner 1 Information

Officer/Owners Name

Title

Social Security

Form of ID

ID #

Issue Date

Expiration Date

State

DOB

Home Phone Number

% of Business Owned

Length of Ownership

Y N

Home Address

Home city

Home state

Home country

Home zip

Owner 1 Information

Officer/Owners Name *

Title

Social Security

Form of ID *

ID # *

Issue Date *

Expiration Date *

State *

DOB *

Home Phone Number

% of Business Owned

Length of Ownership

Y N

Home Address *

Home city *

Home state *

Home country

Home zip *

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