EARLYTERMINATIONFEEREIMBURSEMENTCERTIFICATE

Form 2014

DBA NAME:

MID:
Please submit this certificate as well as the following documentation to your Sales Account Executive:

The debit notice or monthly statement from your previous processor indicating the early termination fee charged.

A copy of your bank statement showing the ending balance at least five (5) business days after the early termination fee debit occurred.

Three (3) consecutive & most recent monthly processing statements. If not provided,MCPS may review your account after the first three (3)
months of active processing to evaluate ETF Reimbursement qualification. MCPS will take the average of the three (3) months Bankcard
volume*.

If average** monthly Bankcard volume is $10,000 or more: 100% of previous processors ETF up to $295.00
If average** monthly Bankcard volume is $5,000-$9,999: 50% of previous processors ETF up to $195.00
*Bankcard volume is defined as Visa, Mastercard, & Discover credit card and signature debit settled transactions only; it does not include pin debit
transactions.
**Average is determined from monthly processing statements provided to MCPS or a review of your MCPS merchant account as indicated above.
Early Termination Fee Reimbursement Certificate Expires 90 calendar days from the date of merchant account approval.

Any early termination fee reimbursement paid by MCPS may be debited from merchant if during the initial term of the MCPS Merchant
Agreement the merchant (1) breaches the Merchant Agreement, including terminating the Merchant Agreement before the expiration of the
initial term, or (2) defaults on any payment pursuant to the Merchant Agreement.

Merchant Signature: Acct. Exec. Name: