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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