Source Of Funds Provider Affidavit (SOFP)

ATM Operator Agreement and Source of Funds Provider Declaration Agreement

ATM Headquarters has prepared this form to easily and correctly complete the federal document required by EVERYONE who is providing cash loading for an ATM. The government wants to know who is filling the cash and where this cash is coming from in their efforts to combat terrorism and money laundering, Please complete the fields below. The completed document will be available for your review at the end.
Where is this ATM installed?
Name of Location (Doing Business As / DBA, or the Name on the Business door)*
DBA Type of Business (Sole Proprietor, Partnership, LLC, Corporation, ETC.)
Physical Street Address of Location*
City, State, Zip of Location*
Phone Number of Location
What does your Business do? (Convenience Store, Bar, Hotel, Hair Salon etc.)
Who will be filling the ATM with the operating cash?
Is the money coming from a Person or a Company?*

A Person or a Sole proprietor with a Social Security NumberA Business with an EIN #
Applicant is an Individual or a Sole Proprietor.

ALL of the information below is REQUIRED by the federal government and the below named person will be subject to a background check for approval.
Name

First NameLast Name
Social Security Number
Address

Persons Physical Street Address

Street Address Line 2

Persons City, State, ZipState / Province

Postal / Zip Code
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Person who is Loading the ATM with Cash Home or Cell Phone Number
The ATM will be filled by a Company with Company funds.

ALL of the information below is REQUIRED by the federal Government and the below named company will be subject to a background check for approval.
Legal Name of Company as stated on documents of incorporation filing.
Company Federal Employer Identification Number (FEIN)
Address

Company Address

Street Address Line 2

Company City, State, ZipState / Province

Postal / Zip Code
22.The undersigned Applicant (“the named ATM Operator/ATM Source of Funds Provider") provides consent to the undersigned ISO (“ISO”)for all the following and affirms that all information contained in this Application for Sponsorship, and any other documentation supplied thereto, is true and correct. Applicant understands that MetaBank, National Association ("Bank") sponsors the ATM Terminal and financial transactions on the ATM Terminal that the Applicant will financially participate in. (NOTE: Cashless, quasi-cash, scrip and any other point-of-sale (POS) transactions are NOT supported by this agreement) The Applicant is applying for an account relationship with Bank, as an ATM Operator and/or ATM Source of Funds Provider sponsored by the Bank. The Applicant acknowledges in order to fight the funding of terrorism and money laundering activities, Bank is required to verify the identity of each person who opens an account with Bank. The Applicant agrees that the Bank is authorized to obtain Consumer and (if applicable) Business Credit Reports and to undertake a criminal Background Investigation in connection with this Application. Applicant authorizes Bank or any of its agents to investigate information or data obtained from this application. If the Applicant is a company, Applicant hereby provided authorization for such Company. Applicant agrees to provide any further information, including financial data, as may be reasonably requested by Bank. Applicant may, upon written request, obtain a complete and accurate disclosure of the nature and scope of the investigation requested hereunder. Applicant acknowledges that Bank may accept or deny this Application in its reasonable discretion. Applicant agrees to comply at all times with applicable laws and regulations as well as banking, regulatory, and network rules, including but not limited to the Plus Systems, Inc., MasterCard/Cirrus, etc. Bylaws and Operating Regulations, which Bylaws and Operating Regulations may be amended from time to time. Applicant understands the Bank may terminate this relationship in Bank's sole discretion or in the event that the Applicant or ISO fail to comply with the Bylaws and Operating Regulations and/or governing regulations. Applicant agrees that they will indemnify and hold harmless the Bank, the processor, the Networks you participate in (including but not limited to Plus System, Inc., MasterCard/Cirrus, etc and Network Members, from and against any and all claims, losses, or damages arising out of Applicant’s or ISO's failure to comply with this Agreement, with applicable laws and regulations, and with the Bylaws and Operating Regulations and/or governing regulations Applicant agrees that the surcharge amount assessed at a sponsored Terminal shall be fair and reasonable and in accordance with Operating Regulations, Bylaws, and/or governing regulation Applicant is not a cannabis related business and is not affiliated with a cannabis related business.
Signature or the Person or Office of the company listed above who will be loading the cash in the ATM

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Name of Person Signing above
Title of Authorized person if is a company
Date*

MonthDayYear
Date
Should be Empty:

ATM Operator Agreement and Source of Funds Provider Declaration Agreement

Where is this ATM installed?

Who will be filling the ATM with the operating cash?

Applicant is an Individual or a Sole Proprietor.

The ATM will be filled by a Company with Company funds.