ACH-W9 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.

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
- Vault Cash AccountSurcharge / Income AccountBoth (Vault Cash and Income)
- CheckingSavings
- Bank Name*
- Account Name*
  Account Name on Check
- Routing Number*
- Account Number*
- Banking Information
  
  For Vault Cash Account
- Banking Information
  
  For Surcharge / Income Account
- CheckingSavings
- 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*
- Please click on the "Review" button located at the bottom to see if all the information are correct then click "Submit".
- For Second ACH
- Vault Cash AccountSurcharge / Income Account
- 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

W-9 Form

Request for Taxpayer Identification Number and Certification
Name*
(as shown on your income tax return)
Business name/disregarded entity name
If different from 'Name'
Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability companyOther
For LLCs: Enter the tax classification
C=C corporation, S=S corporation, P=partnership
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
List account number(s) here (optional)
Part I: Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given as 'Name' above to avoid backup withholding. For individuals, this is generally your social security number (SSN). For other entities, it is your employer identification number (EIN).
Social Security Number
Employer Identification Number
Part II: Certification
Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Signature*
Date*

MonthDayYear
Should be Empty:

ACH Authorization Form

Location Information

Surcharge Information

Banking Information

Banking Information

Banking Information

Banking Information

Banking Information

Banking Information

For Second ACH

W-9 Form

Part I: Taxpayer Identification Number (TIN)

Part II: Certification