Information Profile for State of Florida Agencies



Information Profile for State of Florida Agencies

Credit Card/Electronic Transaction Processing

(Form may be submitted by Email to address shown below)

This form must be completed for each individual location

|1. AGENCY NAME: | |8. LOCATION NAME: | |

|2. AGENCY ADDRESS: | |9. LOCATION ADDRESS: | |

|3. AGENCY CITY: | |10. LOCATION CITY: | |

|4. AGENCY CONTACT: | |11. LOCATION CONTACT: | |

|5. AGENCY TELEPHONE: | |12. LOCATION TELEPHONE: | |

|6. AGENCY EMAIL: | |13. LOCATION EMAIL: | |

|7. AGENCY FAX: | |14. LOCATION FAX: | |

|15. E-SERVICE DESCRIPTION: (Identity of statute, fees, and general program service) |

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|16. DATE SUBMITTED: 17. EXPECTED “LIVE” DATE: |

|18. TRANSACTION TYPE ACCEPTED: |

|MasterCard______Visa_____American Express_____Discover_____Diners_____JCB_____DEBIT_____Electronic Checks_____ |

|POS Conversion_____ |

|19. PROCESSING TYPE: (Check the type of system currently used or planned) |

|Internet_____POS Terminals_____Electronic Cash Register_____IVR_____Other_____ |

|20. ESTIMATED ANNUAL CREDIT CARD VOLUME: | |

|Annual Amount: |Average Transaction: |

|21. ESTIMATED ELECTRONIC CHECK VOLUME: |

| Annual Amount: |Average Transaction: |

|22. NEW ACCOUNT: |23. EXISTING MERCHANT NBR: |

|24. SETTLEMENT INFORMATION: |

| Bank: |Routing Number: |

| Account Number: |

|25. CHARGEBACK INFORMATION: |

| Bank: |Account Number: |Routing Number: |

| Mail Chargebacks to: |

| City: |Zip: |

|26. PAYMENT OF FEES: |

| Invoice Address: |Debit Account Number: |

|27. ACCEPTANCE: Describe agency’s payment acceptance requirements, also describe hardware, software, integration, and interface requirements, including any special configuration, implementation/conversion |

|needs. For POS terminals, will you be using owned equipment (include vendor or type), or will you need equipment? Are communication lines currently installed? Explain the agency’s use of merchant numbers. |

|Does this location require a separate merchant number? |

|(attach additional sheet if necessary) |

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|28. RECONCILIATION: Define transaction identification scheme and reconciliation needs by identifying the following. How is the transaction defined, i.e. invoice number, license number, etc. Identify |

|correlating general ledger information related to the transaction scheme. FOR EXAMPLE: Transaction ID: DBPR-H04-000-2000-2001 indicates Real Estate Renewal using the following GL information: |

|790989998/fund898/etc. How many data capture fields do you need to capture and update GL and application? |

|(attach additional sheet if necessary) |

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|29. APPROVED BY STATE TREASURY 30. REVIEWED BY STATE TECHNOLOGY OFFICE (For State Agencies and Judicial Branch Only)|

| By: Date: | By: Date: |

31. CONTACTS FOR PROCESSING AND ASSISTANCE IN PREPARATION OF THIS FORM

State Agencies and Judicial Branches

Mail, Fax, or Email to: Terry Straub Telephone: (850) 413-2783

Department of Financial Services Fax: (850) 488-0699

200 East Gaines Street Email: terry.straub@

Tallahassee, FL 32399-0344

Units of Local Government

Mail, Fax, or Email directly to: Andrea Morris Telephone: (850) 561-1774

Bank of America Fax: (850) 561-0688

Commercial Card Services Email: andrea.morris@

315 South Calhoun Street

Tallahassee, FL 32301

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