ACH Form

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 #*
Contact Alt #
Contact Fax #
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*

Additional Payees
Payee #2 Amount
Payee #2 Name
Payee #3 Amount
Payee #3 Name
Payee #2 Amount
Payee #2 Name
Payee #3 Amount
Payee #3 Name

Section Closer
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?*

Vault Cash AccountSurcharge / Income AccountBoth (Vault Cash and Income)
Bank Account Type*

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
Bank Account Type

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*

Clear
For Second ACH
Is this account for your vault cash, your surcharge commission, or both?

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

Clear
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