Please Provide The Following Information

Name of Representative: *

Title *

Business Name *

Phone Number (cell): *

Email Address: *

Address

Business Street Address: *

City *

State *

Country

Postal Code *

9-Digit TIN (Taxpayer Identification Number): *

In addition to the above information, please provide the below information to the best of your ability. This will allow us to maximize your return and process your claim quickly.

Type Of Business *

Average Yearly Process Amount:

Please provide the approximate average amount processed annually

Merchant Statements (Optional):

If available, providing merchant statements from the claims period would be helpful but is not mandatory.

Merchant Service Processors & Merchant ID Numbers Associated:

Kindly share the name of your merchant services processor and the associated merchant number

DBAs, Store Numbers, & Locations:

If applicable, please include details about any "Doing Business As" (DBA) names, store numbers, and the addresses of all locations where operations are conducted.

Multiple Processors (if applicable):

If you've used multiple processors in the past, please list them along with the approximate time frames they were used.

Referred By *

Incase none add "NA"

Your assistance with this information will ensure a thorough and efficient review to make sure we maximize your settlement. Please don't hesitate to reach out if you have any questions or need clarification or assistance regarding this request.

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