BANK ACCOUNT CHANGE REQUEST

IMPORTANT: Our Company ACH Identifier number for merchant account bank activity is WFBTS09305. If your bank
requires this information to be on your account to accept debits and credits please contact them to add this number prior
to submitting this form to us for processing.

MERCHANT INFORMATION VERIFICATION (REQUIRED) PLEASE PROVIDE 2 OF THE FOLLOWING

REQUESTOR'S LAST 4 OF
NAME: DEBORAH SUE ANDERSON CURRENT TAX ID:

MERCHANT LAST 4 OF CURRENT

PHONE NUMBER: 616 315 2304 BANK ACCOUNT NUMBER: 1423
MERCHANT DOING LAST 4 OF SSN:
BUSINESS AS: Layin Pipe Plumbing and Design 1386
MERCHANT ID NUMBER
(BEGINS WITH 9305): 930579840176180

SETTLEMENT INFORMATION:
NAME AND PHONE NUMBER ROUTING NUMBER BANK ACCOUNT NUMBER USE THIS ACCOUNT FOR:
OF FINANCIAL INSTITUTION: (SHOWN ON THE BOTTOM OF CHECK) (SHOWN ON THE BOTTOM OF CHECK) (SELECT ALL THAT APPLY)
✔ Daily Settlement
GO2BANK PHONE NUMBER 906 205 2849 124303162 15104928963764 Monthly Billing
1. ✔
✔ Chargebacks
✔ Daily Settlement
GO2BANK PHONE NUMBER 906 205 2849 124303162 15104928963764 Monthly Billing
2. ✔
✔ Chargebacks

FORM INSTRUCTIONS:
1) Please provide a copy of a voided check or bank letter as described below.
2) The account signer will need to sign and date the form.

REQUIREMENT FOR VOIDED CHECK: BANK LETTER REQUIREMENTS:

▪ Business name must match what ▪ Needs to be typed.
we have on file. ▪ Needs to be on bank stationery.
▪ All information on the check must ▪ Document needs to provide routing number and
or account number.
be pre-printed. Starter and
sample checks are not permitted. ▪ Business name referenced on the document must match
what we have on file.
▪ Letter must be signed by an authorized bank official and include their
printed name and phone number or a business card must be affixed.

CONTACT INFORMATION: IF YOU PROCESS DIRECTLY WITH ANY OF THE FOLLOWING COMPANIES,
PLEASE CONTACT THEM DIRECTLY TO MAKE THESE CHANGES:
Email: financialforms@cayan.com
Fax: 617-385-1135 American Express Discover Authorize.net
800-528-5200 800-347-2000 877-447-3938

By signing below, you represent and warrant (i) that the information you have supplied is true and correct in all respects, and (ii) that you have the necessary
power and authority to execute and deliver this request and to take such action on behalf of the Merchant named above. You further acknowledge and
agree that TSYS is entitled to rely on the foregoing and that you will indemnify TSYS and its representatives for any violati on or breach hereof.
Once account is updated any held funds will be released and any rejected fees owed to us for merchant services, gateway or Genius fees will be assessed
against your newly updated bank account within 5 business days. Going forward any funds owed for these services will also be debited from this account.

SIGNER OF THE ACCOUNT MUST SIGN AND DATE THE FORM; OTHERWISE THE REQUEST WILL BE DENIED.

DEBORAH SUE ANDERSON 09/15/2022

SIGNATURE PRINTED NAME DATE

25 Temple Place · Suite 2L · Boston, MA 02111 · 877-986-4445 · beaconpayments.com

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