ACH & Equipment Form

Thank you for requesting the ATM Depot forms package! 💪🙂 Inside this package, you will find the necessary forms to get your ATM Machine Program up and running. You can complete all required fields and sign the documents directly from your computer or mobile device. No need to print these out. Below is a checklist of items included with your ATM forms package.
1. ACH Form: This 1-page form is required in order for us to deposit settlement funds back into your accounts. When someone withdraws cash from your ATM, the Interbank ATM Networks deduct the funds form the Customers Bank and sends the money back to your back account. This from is used to designate where you want your settlement funds and your passive income residuals deposited. An extra ACH Form is included in the package for those who share part of the surcharge and want us to send funds on your behalf. One ACH Form is required for every party that we pay. Voided checks are also required with this form.
2. Equipment Order Form: If you need to order an ATM, use this form. We will contact you by phone to review your order. At that time, we will collect payment once we confirm the order with you. You can also text us a photo of your Credit Card if you prefer that method.

ACH Authorization Form
Location Information
A registered location name and address are required for this ACH. If you don’t have a location yet, please use your business name and address (even if it’s your home) for now. If and when you need to update or change it to a merchant location, you can request a new ACH form when you are ready to install the ATM.
Location Name
This name is shown on ATM receipts
Location Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
First & Last Name
Contact Tel #
Format: (000) 000-0000.
Contact Alt #
Format: (000) 000-0000.
Contact Fax #
Format: (000) 000-0000.
Contact Email Address
example@example.com
ATM Make/Model
Surcharge Information
Surcharge Amount
Tell us how much your ATM will charge customers.
Surcharge Amount
Tell us how much your ATM will charge customers.
Surcharge Splits: Would you like to split the surcharge from your ATM between multiple parties? If you are sharing the surcharge with others and want us to pay them for you so you don't have to do that accounting or make the payments, we can!

Here is how you tell us your Surcharge Splits:
- List all payees receiving surcharge payment below
- Payee #1 is required which is usually you, then select the "Additional Payees" box to enter up to two more payees
- Each payee will need to complete an ACH form, provide a voided check for verification of banking information, and submit a W-9 before payment can be made directly.
  - The W-9 for Payee #1 is included below in this forms package
  - An additional ACH Authorization form can be found here or you can pass this link along to the other parties to fill it out themselves: https://forms.atmdepot.com/ach
    
    Make sure he/she uses the same Location Name and Address
  - An additional W-9 form can be found here or you can pass this link along to the other parties as well: https://forms.atmdepot.com/w9
    
    Payout Name should match Name on W-9
Payee #1 Amount
Payee #1 Name
Payee #1 Amount
Payee #1 Name
- Payee #2 Amount
- Payee #2 Name
- Payee #3 Amount
- Payee #3 Name
- Payee #2 Amount
- Payee #2 Name
- Payee #3 Amount
- Payee #3 Name
- Banking Information
- Banking Information
  
  For Vault Cash Account
- Banking Information
  
  For Surcharge / Income Account
- Banking Information
  
  For Both Vault Cash & Surcharge / Income Account
- Is this account for your vault cash, your surcharge commission, or both?
- Bank Account Type
- Bank Name
- Account Name
  Account Name on Check
- Routing Number
- Account Number
- Banking Information
  
  For Vault Cash Account
- Banking Information
  
  For Surcharge / Income Account
- Bank Account Type
- Bank Name
- Account Name
  Account Name on Check
- Routing Number
- Account Number
- A VOIDED CHECK MUST BE INCLUDED WITH THIS FORM
  
  Any Payee listed above must provide a voided check or bank letter for ACH transfer and a signed ACH Authorization Form.
  
  It is the responsibility of the ATM Operator to verify that all information contained in the exhibits and all other forms submitted to Intelligent eCommerce, Inc (ATMDepot.com), or any modification thereof, are correct and complete. ATMDepot.com and/or its 3rd Party Service Providers has no responsibility to verify any such information and will not be responsible for any claims whatsoever related to any incorrect information submitted to ATMDepot.com. ATM Operator shall notify ATMDepot.com of any disputed item or items. ATMDepot and/or its 3rd Party Service Providers shall not be liable for any amounts which were transmitted in error over twenty-five (25) days prior to the date ATMDepot.com receives notice from ATM Operator, regardless of fault.
  
  I hereby authorize ATMDepot.com and/or its 3rd Party Service Providers to initiate ACH transfers for the following: adjustments, error corrections, chargebacks, daily settlements, maintenance, monthly commissions, and/or debit the account identified herein.
- File Upload
  
  Voided check and/or bank letter required for account specified above.
  Cancelof
- File Upload
  
  Voided check and/or bank letter required for vault cash account specified above.
  Cancelof
- File Upload
  
  Voided check and/or bank letter required for surcharge / income account specified above.
  Cancelof
- Contact Name
  First & Last Name
- Customer Signature
- For Second ACH
- Is this account for your vault cash, your surcharge commission, or both?
- Location Name
  This name is shown on ATM receipts
- Location Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Contact Name
  First & Last Name
- Contact Email Address
  example@example.com
- Contact Name
  First & Last Name
- Customer Signature