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HomeMy Public PortalAbout20120306_JetPay_Contract_signed ISO#mame City of Tybee Island GA T---"""'"""":>irtPerYr 3361 Boyington Drive, Suite 180 A g ent# /Nam River's End Campground & RV Park p�rro�tso72� 9-4800 Fax: (972) 503-9100 JetPay - Merchant Application & Agreement MERCHANT NAME (DBA or Trade Name) CORPORATE/LEGAL NAME (if Different) River's End Campground & RV Park City of Tybee Island, GA LOCATION ADDRESS CORPORATE ADDRESS (0 Different) PO Box 988 PO Box 2749 CITY STATE ZIP CITY STATE ZIP Tybee Island GA 31328 Tybee Island GA 31328 CONTACT NAME CONTACT EMAIL ADDRESS CONTACT TELEPHONE FAX NUMBER FEDERAL TAX ID# Woody Hemphill whemphill @cityoftybee.org 912.786.5518 912.786.4126 58- 6000661 NAME TO APPEAR ON CARDHOLDER'S STATEMENT PHONE 0 TO APPEAR ON CARDHOLDER'S STATEMENT (0 MOTO) COMPANY WEBSITE River's End Campground & RV Park 912,786.5518 www.riversendcampground.com DOES THIS LOCATION CURRENTLY TAKE VISA /MASTERCARD /DISCOVER ®NETWORK? HAVE MERCHANT OR OWNERS /PRINCIPALS EVER BEEN TERMINATED FROM ACCEPTING BANKCARDS FOR THIS BUSINESS OR ANY OTHER BUSINESSES? ❑ No © Yes Reason For Leaving 0 No ❑ Yes (if yes, please explain) OWNERSHIP LOCATION: ❑ Individual/Sole Proprietor ❑ Partnership Building Type: ❑ Shopping Center Q Office Buildin ❑ Corporation ❑ LLC State: Merchant El Owns ❑ Rents Building ❑ Industrial Building ❑ Residence ❑ Non -Profit (Must Provide 503 -C) Area Zoned: 0 Commercial ❑ Industrial ❑ Residential ❑ Private ❑ Publicly Traded Cl Govemment Square Footage: ❑ 0 -500 0 501 -2500 ❑ 2501 -5000 ❑ 5001-10000* Principal Name: SSN:� °7 �' ( � - �,r First; 474 5C +l Middle: Last: E (('G'. �. �'r'""LC -i r� / I.-4--.., / / / r Cp ! 7 j, Ownership: 1 Title: f %,� p�I- - jjj Home Address: • v . . r<M „- j C " .^ . � ' t , , t v a+ 11 �-7 City: tt o o r ..J State6.. 4- Zip: 3 1 .. Date of Birth: 2-143/7 '3 Home Phone : Cell Phone: tiZ -o T't't "'" C 4�. f Email Address: 4 h r-, - , -Vt'V= t sn<tij C: t e " , 1 - 7 , ddd =- . Principal Name: First: Middle: Last: SSN: % Ownership: Title: Home Address: City: State: Zip: Date of Birth: Home Phone : Cell Phone: Email Address: HAVE MERCHANT OR OWNERS /PRINCIPALS EVER FILED: YEARS IN BUSINESS' AVERAGE TICKET MONTHLY VISA/MASTERCARD /DISCOVER ❑ Business Bankruptcy ❑ Personal Bankruptcy 5 90 NETWORK VOLUME (If yes, please explain) $ $ 55 , 000 NATURE OF BUSINESS: REFUND POLICY: (What are you accepting credit cards for? When is the card charged? When is the product or service delivered? Please (Provide details of your return policy.) include any marketing materials that may help describe your product or service.) No refunds w /out receipt, must be unopened, and no weather refunds. All sales final unless Seasonal Sales: Q Yes ❑ No If so, please list high volume months : March - July approved by management (case by case basis). SALES METHOD: OTHER CARDS ACCEPTED' (Place the account number in the space below for existing accounts) Retail Swiped 68 % Keyed with Signatures or Imprints 80 % Mail Order 0 % American Express Q Apply Phone By checking "Apply" for American Express merchant account, you acknowledge that you will receive Inbound Calls 16 % Outbound Calls 0 % Internet 16 % ACH 95 % Terms and Conditions from the card company for which you wish to apply. Please note that these companies are separate entities with their own pricing and acceptance policies. Reporting Options: ❑ Real -Time Reporting ❑ Daily Settlement Reporting ❑ Virtual Terminal Reporting ❑ Other E -Mail Address to send Daily Sales Summaries to: VENDOR REFERENCES (List 2 - include: name, address, and phone number) 1. 2. Acquiring Bank Disclosure Member Bank (Acquirer) Responsibilities: ❑ Merrick Bank 135 Crossways Park North, Woodbury NY 11797, 800- 267 -2256 1. A Visa Member is the only entity approved to extend acceptance of VISA products directly to a Merchant. ❑ Meridian Bank 92 Lancaster Ave Devon, PA 19333 484-568-5000 2. A Visa Member must be a principal (signor) to the Merchant Agreement. 3. The Visa Member is responsible for educating merchants on pertinent Visa Operating Regulations with which Merchants must comply. 4. The Visa Member is responsible for and must provide settlement funds to the Merchant. 5. The Visa Member i responsible for all funds held in reserve that are derived from settlement. t.e.r "Z......____. Xl• / Signatur Officer /Owne Date Processor Disclosure The 'JETPAY' party listed throughout this agreement will refer to one of the checked entities below. ♦ JetPay Merchant Services, LLC, a Texas limited liability company whose address is 3361 Boyington Drive, Ste 180, Carrollton, TX 75006 • JetPay ISO Services, LLC, a Texas limited liability company whose address is 3361 Boyington Drive, Ste 180, Carrollton, TX 75006 ISO#mame City of Tybee Island GA T---"""'"""":>irtPerYr 3361 Boyington Drive, Suite 180 A g ent# /Nam River's End Campground & RV Park p�rro�tso72� 9-4800 Fax: (972) 503-9100 JetPay - Merchant Application & Agreement MERCHANT NAME (DBA or Trade Name) CORPORATE/LEGAL NAME (if Different) River's End Campground & RV Park City of Tybee Island, GA LOCATION ADDRESS CORPORATE ADDRESS (0 Different) PO Box 988 PO Box 2749 CITY STATE ZIP CITY STATE ZIP Tybee Island GA 31328 Tybee Island GA 31328 CONTACT NAME CONTACT EMAIL ADDRESS CONTACT TELEPHONE FAX NUMBER FEDERAL TAX ID# Woody Hemphill whemphill @cityoftybee.org 912.786.5518 912.786.4126 58- 6000661 NAME TO APPEAR ON CARDHOLDER'S STATEMENT PHONE 0 TO APPEAR ON CARDHOLDER'S STATEMENT (0 MOTO) COMPANY WEBSITE River's End Campground & RV Park 912,786.5518 www.riversendcampground.com DOES THIS LOCATION CURRENTLY TAKE VISA /MASTERCARD /DISCOVER ®NETWORK? HAVE MERCHANT OR OWNERS /PRINCIPALS EVER BEEN TERMINATED FROM ACCEPTING BANKCARDS FOR THIS BUSINESS OR ANY OTHER BUSINESSES? ❑ No © Yes Reason For Leaving 0 No ❑ Yes (if yes, please explain) OWNERSHIP LOCATION: ❑ Individual/Sole Proprietor ❑ Partnership Building Type: ❑ Shopping Center Q Office Buildin ❑ Corporation ❑ LLC State: Merchant El Owns ❑ Rents Building ❑ Industrial Building ❑ Residence ❑ Non -Profit (Must Provide 503 -C) Area Zoned: 0 Commercial ❑ Industrial ❑ Residential ❑ Private ❑ Publicly Traded Cl Govemment Square Footage: ❑ 0 -500 0 501 -2500 ❑ 2501 -5000 ❑ 5001-10000* Principal Name: SSN:� °7 �' ( � - �,r First; 474 5C +l Middle: Last: E (('G'. �. �'r'""LC -i r� / I.-4--.., / / / r Cp ! 7 j, Ownership: 1 Title: f %,� p�I- - jjj Home Address: • v . . r<M „- j C " .^ . � ' t , , t v a+ 11 �-7 City: tt o o r ..J State6.. 4- Zip: 3 1 .. Date of Birth: 2-143/7 '3 Home Phone : Cell Phone: tiZ -o T't't "'" C 4�. f Email Address: 4 h r-, - , -Vt'V= t sn<tij C: t e " , 1 - 7 , ddd =- . Principal Name: First: Middle: Last: SSN: % Ownership: Title: Home Address: City: State: Zip: Date of Birth: Home Phone : Cell Phone: Email Address: HAVE MERCHANT OR OWNERS /PRINCIPALS EVER FILED: YEARS IN BUSINESS' AVERAGE TICKET MONTHLY VISA/MASTERCARD /DISCOVER ❑ Business Bankruptcy ❑ Personal Bankruptcy 5 90 NETWORK VOLUME (If yes, please explain) $ $ 55 , 000 NATURE OF BUSINESS: REFUND POLICY: (What are you accepting credit cards for? When is the card charged? When is the product or service delivered? Please (Provide details of your return policy.) include any marketing materials that may help describe your product or service.) No refunds w /out receipt, must be unopened, and no weather refunds. All sales final unless Seasonal Sales: Q Yes ❑ No If so, please list high volume months : March - July approved by management (case by case basis). SALES METHOD: OTHER CARDS ACCEPTED' (Place the account number in the space below for existing accounts) Retail Swiped 68 % Keyed with Signatures or Imprints 80 % Mail Order 0 % American Express Q Apply Phone By checking "Apply" for American Express merchant account, you acknowledge that you will receive Inbound Calls 16 % Outbound Calls 0 % Internet 16 % ACH 95 % Terms and Conditions from the card company for which you wish to apply. Please note that these companies are separate entities with their own pricing and acceptance policies. Reporting Options: ❑ Real -Time Reporting ❑ Daily Settlement Reporting ❑ Virtual Terminal Reporting ❑ Other E -Mail Address to send Daily Sales Summaries to: VENDOR REFERENCES (List 2 - include: name, address, and phone number) 1. 2. Acquiring Bank Disclosure Member Bank (Acquirer) Responsibilities: ❑ Merrick Bank 135 Crossways Park North, Woodbury NY 11797, 800- 267 -2256 1. A Visa Member is the only entity approved to extend acceptance of VISA products directly to a Merchant. ❑ Meridian Bank 92 Lancaster Ave Devon, PA 19333 484-568-5000 2. A Visa Member must be a principal (signor) to the Merchant Agreement. 3. The Visa Member is responsible for educating merchants on pertinent Visa Operating Regulations with which Merchants must comply. 4. The Visa Member is responsible for and must provide settlement funds to the Merchant. 5. The Visa Member i responsible for all funds held in reserve that are derived from settlement. t.e.r "Z......____. Xl• / Signatur Officer /Owne Date Processor Disclosure The 'JETPAY' party listed throughout this agreement will refer to one of the checked entities below. ♦ JetPay Merchant Services, LLC, a Texas limited liability company whose address is 3361 Boyington Drive, Ste 180, Carrollton, TX 75006 • JetPay ISO Services, LLC, a Texas limited liability company whose address is 3361 Boyington Drive, Ste 180, Carrollton, TX 75006 • IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. EXHIBIT 1 — Please also include the below with your completed merchant Merchant PCI DSS Information application and agreement. Is your organization currently PCI DSS Compliant? Yes ❑i No ❑ ki If Yes. please include the most recent cony of your PCI DSS certification. thus automatically opting your Voided Check or Bank Verification Letter account out dike JetPay PCI Compliance program. but not out of PCI Breach Insurance ❑ Copy of Principal's Driver's License 0 Secondary Principal Identification (one of the below qualify) PCI Contact (if different than primary contact): • Current Auto Insurance Card or Registration Michael Bodine mbodine @cityoftybee.org • Current Utility Bill Name Email • Employer ID Card with Photo Active PCI DSS compliance is required to obtain a merchant account. By participating in JetPay's PCI Compliance • Most Recent Complete Tax Return program, you will gain access to PCI DSS compliance documentation, assistance in completing tasks required to become • Most Recent Real Estate Bill complaint and gain PCI breach insurance policy coverage. You coverage will begin on the first day of the month after • Completed W - Form signing this agreement. The above contact will be contacted with login information. Contact complianceaietpay.com for additional information regarding the JetPay Compliance program and PCI Breach Insurance. Merchant Application and Agreement Acceptance By executing this Merchant Application and Agreement on behalf of the merchant described above (the "Merchant "), the undersigned individual(s): (i) represent(s) and warrant(s) that all information contained in this Merchant Application is true, correct and complete as of the date of this Merchant Application and any fines, losses or penalties that arise do to in- accurate information will be assessed to the merchant, and that such individual(s) have the requisite corporate power and authority to complete and submit this Merchant Application and Agreement and provide the acknowledgements, authorizations and agreements set forth below, both on behalf of the Merchant and individually; (n) acknowledge(s) that the information contained in this Merchant Application is provided for the purpose of obtaining, pricing and acceptance for processing or maintaining a merchant account with JETPAY and Bank on behalf of the Merchant; (iii) authorize JETPAY and Bank to investigate the credit of the Merchant and each person listed on this Merchant Application; and (iv) agree, on behalf of the Merchant and in the event this Merchant Application is accepted and executed by Bank and JETPAY, to all of the terms and conditions set forth in the Merchant Agreement. The Merchant and undersigned individuals understand it is their responsibility to carefully review the terms and conditions of the merchant agreement provided and available at www. jetpay .comlmerchantlaboutmerchant terms.php, which are hereby incorporated by reference. By signing below, you acknowledge that you have read, understood and agree to those terms and conditions and that you agree to accept electronic notification of any changes to those terms and conditions as updated from time to time at the JetPay WEB address for merchant terms listed above. If the merchant is a corporation, its proper Corporate Officers must sign. This Agreement may be signed by one or more counterparts and all signed agreements shall be considered as one. Merchant: ! Bank Principal 1: Date: / �c+i'� B (Sign ure of Officer /Owner) /// y Date: Name and Title: Principal 2: Date: (Signature of Officer /Owner) JETPAY: By: Date: Name and Title: Corporate Resolution 1. , the duly elected, qualified and acting of , a (the "Company), do hereby certify as follows: Corporate Secretary* Office Title Legal Corporate Name of Co. Incorporation Status The following resolutions were duly adopted by the board of directors/managing member(s) /general partners (circle one) of the Company: WHEREAS, the Company desires to enter into a Merchant Agreement (the "Merchant Agreement") with Bank and JETPAY, a copy of which Merchant Agreement is attached hereto as Exhibit "A "; WHEREAS, pursuant to the terms of the Merchant Agreement, Bank and JETPAY will provide certain credit card financing and processing for VISA, MASTERCARD and/or Discover Network credit card purchases made by the Company's customers; WHEREAS, pursuant to the terms of the Merchant Agreement, (a) the Company may be required to establish a Reserve Account (as defined in the Merchant Agreement) and (b) Bank may require the Company to direct certain funds relating to credit card purchases to such Reserve Account; WHEREAS, pursuant to the terms of the Merchant Agreement, Bank may require the Company to execute instruments evidencing Bank's security interest in the Operating Account (as defined in the Merchant Agreement) and Reserve Account; and WHEREAS, pursuant to the terms of the Merchant Agreement, the Company is required to comply with strict requirements concerning the processing of credit card transactions and the sale of the Companys products. NOW, THEREFORE, BE IT RESOLVED, that the Merchant Agreement by and among the Company, Bank and JETPAY, pursuant to which Bank and JETPAY shall act as the Company's exclusive provider of VISA , MASTERCARD and /or Discover Network credit card financing and processing services, is hereby approved and adopted art the form attached to these resolutions, together with such additions, changes or modifications as may be deemed necessary, advisable or appropriate by the officer(s) executing or causing the same to be completed; and RESOLVED FURTHER, that in connection with the Merchant Agreement, the appropriate officer(s) of the Company is /are hereby authorized to establish (a) an Operating Account into which funds from credit card sales by the Company will be directed, and (b) if necessary, a Reserve Account into which funds from credit card sales by the Company may be directed by Bank in accordance with the provisions of the Merchant Agreement; RESOLVED FURTHER, that the Company hereby grants Bank a security interest in the funds held by the Company in the Operating Account and Reserve Account, and the appropriate officer(s) of the Company is /are hereby authorized to execute all documents reasonably required by Bank to perfect such security interests; RESOLVED FURTHER, that the appropriate officer(s) of the Company is /are hereby authorized to enter into such additional agreements, and take such additional actions as may be reasonably required by Bank or JETPAY in connection with the Merchant Agreement; and RESOLVED FURTHER, that the Secretary/managing member /general partner (circle one) of the Company is hereby authorized to deliver to Bank and JETPAY a Certificate (i) identifying the officers Odle Company, (u) verifying the signatures of such officers, and (iii) certifying a copy of these resolutions, and Bank and JETPAY are hereby authorized to rely on such Certificate until formally advised by a like certificate of any changes therein, and is hereby authorized to rely on any such additional certificates. 2. Each person listed below (an "Officer') (i) holds the office in the Company indicated opposite his or her name on the date hereof, (ii) the signature appearing opposite his or her name is the genuine signature of each such officer, (iii) each such Officer, acting individually, is authorized to execute and deliver the Merchant Agreement and each of the agreements and documents contemplated by the Merchant Agreement (collectively, the Transaction Documents") on behalf of the Company, and (iv) each such Officer, acting individually, is authorized to perform the Company's obligations under the Transaction Documents on behalf of the Company: 3. NAME OFFICER SIGNATURE IN WITNESS WHEREOF, I have executed this Certificate this day of 20_ Sign: Name: TITLE: Corporate Secretary' or Print Officer Title •` If only one Corporate Officer will complete the entire Corporate Resolution and sign as witness; ff more than one Corporate Officer, Corporate Secretary is to complete top portion of Resolution, have all other Officers sign body of Resolution, and Corporate Secretary is to sign as Witness. Guarantor of Payment By signing below, each individual or entity (a "Guarantor') jointly and severally (if there is more than one Guarantor) and unconditionally guarantees to JETPAY and Bank the prompt payment and performance of all obligations of the Merchant identified above under the Merchant Agreement (as that term is defined above), including, without limitation, al promises and covenants of the Merchant, and all amounts payable by the Merchant under the Merchant Agreement, including, without limitation, interest, costs and other expenses, such as attorney's fees and court costs. This means, among other things, that JETPAY or Bank can demand performance or payment from any Guarantor if the Merchant fails to perform any obligation or pay what the Merchant owes under the Agreement. Each Guarantor agrees that his or her liability under this guaranty will not be limited or canceled because: (1) the Merchant Agreement cannot be enforced against the Merchant; (2) either JETPAY or Bank agrees to changes or modifications to the Merchant Agreement; (3) JETPAY or Bank releases any other Guarantor or the Merchant from any obligation under the Merchant Agreement; (4) a law, regulation or order of any public authority affects the rights of either JETPAY or Bank under the Merchant Agreement; and /or (5) anything else happens that may affect the rights of either JETPAY or Bank against the Merchant or any other Guarantor. Each Guarantor further agrees that: (a) JETPAY and Bank each may delay enforcing any of its rights under this guaranty without losing such rights; (b) JETPAY and Bank each can demand payment from such Guarantor without first seeking payment from the Merchant or any other Guarantor; and (c) such Guarantor will pay all court costs, attorney's fees and collection costs incurred by either JETPAY or Bank in connection with the enforcement of any terms of the Merchant Agreement or this guaranty, whether or not there is a lawsuit, and such additional fees and costs a ay be directed by a court. Merchant: q Principal t.� Date: O or Principal 2: Date: `r_ (Signal ' of Ofricer /Owner) (Signature of Officer /Owner) /15 /1(. ,ti fir° 71 C /Tj/ d F TWEE 414.9c.-)i)(4\ Form W -9 (Rev. 1 -2011) Page 2 The person who gives Form W -9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding. establishing its U.S. status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the share of net income from the partnership conducting a trade or business Requester of Form W -9. in the United States is in the following cases: Also see Special rules for partnerships on page 1. • The U.S. owner of a disregarded entity and not the entity, • The U.S. grantor or other owner of a grantor trust and not the trust, Updating Your Information and You must provide updated information to any person to whom you • The U.S. trust (other than a grantor trust) and not the beneficiaries of claimed to be an exempt payee if you are no longer an exempt payee the trust. and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if Foreign person. If you are a foreign person, do not use Form W -9. you are a C corporation that elects to be an S corporation, or if you no Instead, use the appropriate Form W -8 (see Publication 515, longer are tax exempt. In addition, you must furnish a new Form W -9 if Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account, for example, if the grantor of a Nonresident alien who becomes a resident alien. Generally, only a grantor trust dies. nonresident alien individual may use the terms of a tax treaty to reduce Penalties or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions Failure to furnish TIN. If you fail to fumish your correct TIN to a specified in the saving clause may permit an exemption from tax to requester, you are subject to a penalty of $50 for each such failure continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect. become a U.S. resident alien for tax purposes. Civil penalty for false information with respect to withholding. If you If you are a U.S. resident alien who is relying on an exception make a false statement with no reasonable basis that results in no contained in the saving clause of a tax treaty to claim an exemption backup withholding, you are subject to a $500 penalty. from U.S. tax on certain types of income, you must attach a statement Criminal penalty for falsifying information. Willfully falsifying to Form W -9 that specifies the following five items: certifications or affirmations may subject you to criminal penities 1. The treaty country. Generally, this must be the same treaty under including fines and /or imprisonment. which you claimed exemption from tax as a nonresident alien. Misuse of TINs. If the requester discloses or uses TINs in violation of 2. The treaty article addressing the income. federal law, the requester may be subject to civil and criminal penalties. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. Specific Instructions 4. The type and amount of income that qualifies for the exemption Name from tax. 5. Sufficient facts to justify the exemption from tax under the terms of If you are an individual, you must generally enter the name shown on the treaty article. your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Example. Article 20 of the U.S. -China income tax treaty allows an Administration of the name change, enter your first name, the last name exemption from tax for scholarship income received by a Chinese shown on your social security card, and your new last name. student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in If the account is in joint names, list first, and then circle, the name of the United States exceeds 5 calendar years. However, paragraph 2 of the person or entity whose number you entered in Part 1 of the form. the first Protocol to the U.S. -China treaty (dated April 30, 1984) allows Sole proprietor. Enter your individual name as shown on your income the provisions of Article 20 to continue to apply even after the Chinese tax return on the "Name" line. You may enter your business, trade, or student becomes a resident alien of the United States. A Chinese "doing business as (DBA)" name on the "Business name /disregarded student who qualifies for this exception (under paragraph 2 of the first entity name" line. protocol) and is relying on this exception to claim an exemption from tax Partnership, C Corporation, or S Corporation. Enter the entity's name on his or her scholarship or fellowship income would attach to Form on the "Name" line and any business, trade, or "doing business as W -9 a statement that includes the information described above to (DBA) name" on the "Business name /disregarded entity name" line. support that exemption. Disregarded entity. Enter the owner's name on the "Name" line. The If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the "Name" line should never be a withholding, give the requester the appropriate completed Form W -8. disregarded entity. The name on the "Name" line must be the name What is backup withholding? Persons making certain payments to you shown on the income tax return on which the income will be reported. must under certain conditions withhold and pay to the IRS a percentage For example, if a foreign LLC that is treated as a disregarded entity for of such payments. This is called "backup withholding." Payments that U.S. federal tax purposes has a domestic owner, the domestic owner's may be subject to backup withholding include interest, tax - exempt name is required to be provided on the "Name" line. If the direct owner interest, dividends, broker and barter exchange transactions, rents, of the entity is also a disregarded entity, enter the first owner that is not royalties, nonemployee pay, and certain payments from fishing boat disregarded for federal tax purposes. Enter the disregarded entity's operators. Real estate transactions are not subject to backup name on the "Business name /disregarded entity name" line. If the owner withholding. of the disregarded entity is a foreign person, you must complete an You will not be subject to backup withholding on payments you appropriate Form W-8. receive if you give the requester your correct TIN, make the proper Note. Check the appropriate box for the federal tax classification of the certifications, and report all your taxable interest and dividends on your person whose name is entered on the "Name" line (Individual /sole tax return. proprietor, Partnership, C Corporation, S Corporation, Trust/estate). Payments you receive will be subject to backup Limited Liability Company (LLC). If the person identified on the withholding if: "Name" line is an LLC, check the "Limited liability company" box only 1. You do not furnish your TIN to the requester, and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal 2. You do not certify your TIN when required (see the Part II tax purposes, enter "P" for partnership. If you are an LLC that has filed a instructions on page 3 for details), Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for 3. The IRS tells the requester that you furnished an incorrect TIN, C corporation or "S" for S corporation. If you are an LLC that is 4. The IRS tells you that you are subject to backup withholding disregarded as an entity separate from its owner under Regulation because you did not report all your interest and dividends on your tax section the LLC box 3 (except for employment owner o the and (required tax), a return (for reportable interest and dividends only), or not check the LLC b unless the w s another e the LLC (required be identified on the "Name" line) is another LLC that is not disregarded for 5. You do not certify to the requester that you are not subject to federal tax purposes. If the LLC is disregarded as an entity separate backup withholding under 4 above (for reportable interest and dividend from its owner, enter the appropriate tax classification of the owner accounts opened after 1983 only). identified on the "Name" line. Form W -9 (Rev. 1 -2011) Page 3 Other entities. Enter your business name as shown on required federal Part I. Taxpayer Identification Number (TIN) tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You Enter your TIN in the appropriate box. If you are a resident alien and may enter any business, trade, or DBA name on the "Business name/ you do not have and are not eligible to get an SSN, your TIN is your IRS disregarded entity name" line. individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN Exempt Payee below. If you are exempt from backup withholding, enter your name as If you are a sole proprietor and you have an EIN, you may enter either described above and check the appropriate box for your status, then your SSN or EIN. However, the IRS prefers that you use your SSN. check the "Exempt payee" box in the line following the "Business name/ If you are a single- member LLC that is disregarded as an entity disregarded entity name," sign and date the form. separate from its owner (see Limited Liability Company (LLC) on page 2), Generally, individuals (including sole proprietors) are not exempt from enter the owner's SSN (or EIN, if the owner has one). Do not enter the backup withholding. Corporations are exempt from backup withholding disregarded entity's EIN. If the LLC is classified as a corporation or for certain payments, such as interest and dividends. partnership, enter the entity's EIN. Note. If you are exempt from backup withholding, you should still Note. See the chart on page 4 for further clarification of name and TIN complete this form to avoid possible erroneous backup withholding. combinations. The following payees are exempt from backup withholding: How to get a TIN. If you do not have a TIN, apply for one immediately. 1. An organization exempt from tax under section 501(a), any IRA, or a To apply for an SSN, get Form SS -5, Application for a Social Security custodial account under section 403(b)(7) if the account satisfies the Card, from your local Social Security u also get office or get this form online at www.ssa.gov. You may also get this form by calling requirements of section 401(f)(2), 1- 800 - 772 -1213. Use Form W -7, Application for IRS Individual Taxpayer 2. The United States or any of its agencies or instrumentalities, Identification Number, to apply for an ITIN, or Form SS -4, Application for 3. A state, the District of Columbia, a possession of the United States, Employer Identification Number, to apply for an EIN. You can apply for or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov /businesses and clicking on Employer Identification Number (EIN) under Starting a 4. A foreign government or any of its political subdivisions, agencies, Business. You can get Forms W -7 and SS -4 from the IRS by visiting or instrumentalities, or IRS.gov or by calling 1- 800 -TAX -FORM (1- 800 - 829 - 3676). 5. An international organization or any of its agencies or If you are asked to complete Form W -9 but do not have a TIN, write instrumentalities. "Applied For" in the space for the TIN, sign and date the form, and give Other payees that may be exempt from backup withholding include: it to the requester. For interest and dividend payments, and certain 6. A corporation, payments made with respect to readily tradable instruments, generally 7. A foreign central bank of issue, you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60 -day rule does 8. A dealer in securities or commodities required to register in the not apply to other types of payments. You will be subject to backup United States, the District of Columbia, or a possession of the United withholding on all such payments until you provide your TIN to the States, requester. 9. A futures commission merchant registered with the Commodity Note. Entering "Applied For" means that you have already applied for a Futures Trading Commission, TIN or that you intend to apply for one soon. 10. A real estate investment trust, Caution: A disregarded domestic entity that has a foreign owner must 11. An entity registered at all times during the tax year under the use the appropriate Form W -8. Investment Company Act of 1940, Part II. Certification 12. A common trust fund operated by a bank under section 584(a), To establish to the withholding agent that you are a U.S. person, or 13. A financial institution, resident alien, sign Form W -9. You may be requested to sign by the 14. A middleman known in the investment community as a nominee or withholding agent even if item 1, below, and items 4 and 5 on page 4 custodian, or indicate otherwise. 15. A trust exempt from tax under section 664 or described in section For a joint account, only the person whose TIN is shown in Part I 4947. should sign (when required). In the case of a disregarded entity, the The following chart shows types of payments that may be exempt person identified on the "Name" line must sign. Exempt payees, see from backup withholding. The chart applies to the exempt payees listed Exempt Payee on page 3. above, 1 through 15. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4. IF the payment is for ... THEN the payment is exempt 1. Interest, dividend, and barter exchange accounts opened for ... before 1984 and broker accounts considered active during 1983. Interest and dividend payments All exempt payees except You must give your correct TIN, but you do not have to sign the certification. for 9 2. Interest, dividend, broker, and barter exchange accounts Broker transactions Exempt payees 1 through 5 and 7 opened after 1983 and broker accounts considered inactive during through 13. Also, C corporations. 1983. You must sign the certification or backup withholding will apply. If Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing patronage dividends your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. Payments over $600 required to be Generally, exempt payees 3. Real estate transactions. You must sign the certification. You may reported and direct sales over 1 through 7 cross out item 2 of the certification. $5,000 'See Form 1099 -MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099 -MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attomey, and payments for services paid by a federal executive agency. Form W -9 (Rev. 1 -2011) Page 4 4. Other payments. You must give your correct TIN, but you do not Note. If no name is circled when more than one name is listed, the have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed. have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for Secure Your Tax Records from Identity Theft rents, royalties, goods (other than bills for merchandise), medical and Identity theft occurs when someone uses your personal information health care services (including payments to corporations), payments to such as your name, social security number (SSN), or other identifying a nonemployee for services, payments to certain fishing boat crew information, without your permission, to commit fraud or other crimes. members and fishermen, and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return (including payments to corporations). using your SSN to receive a refund. 5. Mortgage interest paid by you, acquisition or abandonment of To reduce your risk: secured property, cancellation of debt, qualified tuition program .protect your SSN, payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You • Ensure your employer is protecting your SSN, and must give your correct TIN, but you do not have to sign the certification. • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a What Name and Number To Give the Requester notice from the IRS, respond right away to the name and phone number For this type of account Give name and SSN of: printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you 1. Individual The individual think you are at risk due to a lost or stolen purse or wallet, questionable 2. Two or more individuals (joint The actual owner of the account or, credit card activity or credit report, contact the IRS Identity Theft Hotline account) if combined funds, the first at 1- 800 - 908 -4490 or submit Form 14039. individual on the account 3. Custodian account of a minor The minor For more information, see Publication 4535, Identity Theft Prevention (Uniform Gift to Minors Act) and Victim Assistance. 4. a. The usual revocable savings The grantor Victims of identity theft who are experiencing economic harm or a trust (grantor is also trustee) system problem, or are seeking help in resolving tax problems that have b. So called trust account that is The actual owner not been resolved through normal channels, may be eligible for not a legal or valid trust under Taxpayer Advocate Service (TAS) assistance. You can reach TAS by state law calling the TAS toll -free case intake line at 1- 877 - 777 -4778 or TTY/TDD 5. Sole proprietorship or disregarded The owner' 1 - 800 - 829 - 4059. entity owned by an individual 6. Grantor trust filing under Optional The grantor* Protect yourself from suspicious emails or phishing schemes. Form 1099 Filing Method 1 (see Phishing is the creation and use of email and websites designed to Regulation section 1.671 4(b)(2)(i)(A)) mimic legitimate business emails and websites. The most common act For this type of account Give name and EIN of: is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering 7. Disregarded entity not owned by an The owner private information that will be used for identity theft. individual 8. A valid trust, estate, or pension trust Legal entity ° The IRS does not initiate contacts with taxpayers via emails. Also, the 9. Corporation or LLC electing The corporation IRS does not request personal detailed information through email or ask corporate status on Form 8832 or taxpayers for the PIN numbers, passwords, or similar secret access Form 2553 information for their credit card, bank, or other financial accounts. 10. Association, club, religious, The organization If you receive an unsolicited email claiming to be from the IRS, charitable, educational, or other forward this message to phishing @irs.gov. You may also report misuse tax - exempt organization of the IRS name, logo, or other IRS property to the Treasury Inspector 11. Partnership or multi member LLC The partnership General for Tax Administration at 1- 800 - 366 -4484. You can forward 12. A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at: spam @uce.gov 13. Account with the Department of The public entity or contact them at www.ftc.gov/idtheft or 1- 877 - IDTHEFT Agriculture in the name of a public (1 entity (such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce government, school district, or your risk. prison) that receives agricultural program payments 14. Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671- 4(b)(2)(i)(B)) ' List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished. 2 Circle the minor's name and furnish the minor's SSN. 3 You must show your individual name and you may also enter your business or "DBA" name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. ° List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1. `Note. Grantor also must provide a Form W -9 to trustee of trust. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. "*"."": PPD /CCD ACH SEC Code Regulations PPD is a credit or debit initiated by a company to a recurring or single entry authorization from a merchant to transfer funds to or from a customer. The customer must sign an agreement or authorization. Authorization must be easily identifiable as an authorization and must clearly and conspicuously state the term of the agreement. Electronic authorization must be able to be displayed on a computer screen or other visual display, and electronic signatures must include digital signatures and security codes. The merchant is squired to have the following language on the authorization form: 1. The authorization may contain language such as "I, the customer, hereby authorize the merchant to initiate an ACH debit. The a„;count information collected by the merchant will be filed and authorizes for future debiting to pay for any fees for the merchant's services. If I chose a subscription based plan, I authorize recurring transactions in accordance to the plan terms." 2. Any agreement, authorization, written statement under penalty of perjury, or other record required must be retained as an electronic record that accurately reflects the information in the record, and is capable of being accurately reproduced for later reference, whether by transmission, printing, or otherwise. CCD is identical to PPD except that the transaction is considered 'business to business'. All PPD requirements apply. For example: 3. I, [ACCOUNT HOLDER NAME] hereby authorize [MERCHANT] to initiate an ACH debit. The account information collected by the merchant will be filed and authorized for future debiting to pay for any fees for the merchant's services. This authority is to remain in full force and effect until [DATE] or [MERCHANT] has received written notification to terminate authorization [# OF DAYS] in advance of termination. I understand and agree that my account will be drafted on or about the day of the month for the current month's installment and any additional fees agreed to in this Lease. Any agreement, authorization, written statement under penalty of perjury, or other record required must be retained as an electronic record that accurately reflects the information in the record, and is capable of being accurately reproduced for later reference, whether by transmission, printing, or otherwise. Bank Name: ., )" u` e City: Sin v,tarbri State: C7' 7l Zip: j Phone Number: Transit/ABA No. 3. £ s Account No. ere,' /41)00 c: 4 Account Holder Name: 7y � Date: 1 /25 / 1 2— Signature: IA ° _ AA ** *This is a sample authorization form is to be edited to reflect the merchant intending to use it, but must retain the language required by NACHA regulation. You as the merchant should remit your own form you will provide to your customers authorizing Ach transactions from their bank accounts. The merchant should retain the signed authorization on file for the duration of the contract and TWO years after for liability purposes for proof of authorization should there be a dispute. or c Form W -9 Request for Taxpayer Give Form to the (Rev. January 2011) requester. Do not Department of the Treasury Identification Number and Certificatio send to the IRS. Internal Revenue Service Name (as shown on your income tax return) City of Tybee Island, Georgia N Business name /disregarded entity name, if different from above rn River's End Campground & RV Park ca o- Check appropriate box for federal tax c O classification (required): 111 Individual /sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate C 0 n Li Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) ► ri Exempt payee 02 a U ❑ Other (see instructions) ■ ' Address (number, street, and apt. or suite no.) Requester's name and address (optional) a PO Box 988 cn • City, state, and ZIP code cn Tybee Island, GA 31328 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line I Social security number to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a — resident alien, sole proprietor, or disregarded entity, see the Part 1 instructions on page 3. For other - - entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number number to enter. — — — — 5 8- 6 0 0 0 6 6 1 Part I1 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Signature of Here U.S. person ■ ✓ Date ■ General Instructions Note. If a requester gives you a form other than Form W -9 to request your TIN, you must use the requester's form if it is substantially similar Section references are to the Internal Revenue Code unless otherwise to this Form W -9. noted. Definition of a U.S. person. For federal tax purposes, you are Purpose of Form considered a U.S. person if you are: A person who is required to file an information return with the IRS must • An individual who is a U.S. citizen or U.S. resident alien, obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States, you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate), or of debt, or contributions you made to an IRA. • A domestic trust (as defined in Regulations section 301.7701 -7). Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or requester) and, when applicable, to: business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. 1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W -9 has not been received, a number to be issued), partnership is required to presume that a partner is a foreign person, 2. Certify that you are not subject to backup withholding, or and pay the withholding tax. Therefore, if you are a U.S. person that is a 3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W -9 to the partnership to establish your U.S. allocable share of any partnership income from a U.S. trade or business status and avoid withholding on your share of partnership income. is not subject to the withholding tax on foreign partners' share of effectively connected income. Cat. No. 10231X Form W -9 (Rev. 1 - 2011) Schedule A Merchant Name: Rivers End Campground & RV Park Visa, MasterCard and Discover Network Interchange — Interchange is the exchange of clearing records between Members. Interchange Fees are paid to a Member Issuer by a Member Acquirer for reimbursement of expenses associated with the Gearing and settlement of an interchange transaction. Interchange Fees are established by Visa and MasterCard and if changed shall be applicable to Merchant as of the effective date established by Visa and MasterCard. BIN and Bank Fees — BIN is the bank identifying number and fees associated with authorization. clearing and deposits at an Association Bank. Visa Assessments - .11 %as of Agreement date; subject to change by Visa USA Inc. and if changed shall be applicable to Merchant as of the effective date established by Visa USA. Inc. MasterCard Assessments - .11% as of Agreement date; subject to adjustment by MasterCard International and if changed shall be applicable to Merchant as of the effective date established by MasterCard International. Discover Network Assessments - .10% as of Agreement date; subject to change by Discover Network and if changed shall be applicable to Merchant as of the effective date established by Discover Network. Optional Services (by request) Interchange + Visa/ MasterCard / Discover Discount Rate 0.30% Transaction Recycling ('per transaction ") $0.50 Visa/ MasterCard / Discover Authorization Fee $0.10 Account Updater ( "per update /per attempt ") $0.50 Visa/ MasterCard / Discover Settlement Fee $0.10 Verified by Visa (Payer Authentication) $0.50 American Express Authorization Fee $ 0.25 SecureCode (Payer Authentication) $0.50 AVS Fee $0.05 CVV2 Fee $0.05 Application Set Up Fee (Non- Refundable) $50.00 Monthly Minimum Fee $25.00 Monthly Account Maintenance Fee $15.00 JetPay Online Reporting System (Yes or No) -› Yes GetReporting.com Access (monthly) Monthly Help Desk Fee $ 0.75 - Reminder- If Yes, Send Access Request Form $5.00 Voice ( "ARU ") Authorization Fee $ 0.75 ACH Rates & Fees (Select YES or NO) Monthly Account Maintenance Fee waived Chargeback Fee $ 25.00 Monthly Minimum Fee $10.00 Account File Change Fee $ 10.00 ACH Processing Transaction Fee (per ACH) $0.40 ACH /Deposit Fee (per ACH) $0.20 ACH Return Fee $5.00 Gateway Fee (per Tran) waived ACH Reject Fee $ 25.00 Early Termination Fee $200.00 PCI DSS Compliance Including Breach Insurance* Discount Frequency Daily Monthly Access $ 12.95 'Merchant must choose an option on the Schedule A or will default to monthly billing. Merchants can opt out of the PCI Compliance program but will be required to provide full compliance certification through their current provider as well as a copy of the merchant's active PCI Breach insurance. Schedule A is based on Merchant's representation of transaction size and volume and method of processing as represented on the Merchant Application and Merchant acknowledges that, to the extent Merchant's actual transaction size and volume and method of processing differ from such representation, Bank or JETPAY may, at their option, from time to time, modify Schedule A. JetPay reserves the right to modify or amend any of the reserve, hold, rates, t fees or charges set forth in this Schedule in accordance with the terms of the Merchant Agreement Printed Name YaPI ed 14 VU s, • Signed: • Date: I ' lz-td Rev 070110 Fax to: Errin Frankman First PREMIER Bank (605)970'0760 JETPAY, LLC — NEW CLIENT REQUEST Legal Business Name River's End Campground & RV Park Trade Name (DBA) River's End Campground & RV Park Address PO Box 9W8 City Tybee Island State GA Zip 31328 Tax Identification Numwer(TIN)50-b00O66l 1. OFAC Check Cokl pleted, with no matches found? Yes (Documentation o this check MUST be included in client's underwriting file) 2. Copy of Certificate o Articles of Incorporation, Organizafon, etc. obtained AND filed? Yes (other possible documnts used for verification might inchde: Partnership Agreement, State Website Search, etc.) If no, what method was tsed to verify legitimacy of conviany? Business license 3. Copy of Official Document Verifying Tax Identificat; Jn Number (TIN) obtained AND filed? Yes (Le. Tax Return 'must be sigced by prepare* qua - terly payroll form; IRS TIN ISS-4 form] or 501(c)3 letter) Specify document used to verily Tax ID form unp']/ed and enclosed and 4. Type of Business (i.e. manufacturg compan RV Park/Campground/Store 5. Reason for the Transactions (i.e. payroll) uJmeut Telemarketing Yes No X Internet Gambling Yes No X Internet, Mali or Teleplione Sales of T bucxo Yes No X Consumer Debits Re/ated to Pornogr'phy or "Adult" Activity Yes No X 6. Website(s) utilized for marketin', purposes Y's 7. Standard Entry Class (SEC) Code(s) Used PPE), CCD, TEL, WEB 8. Debits, Credits, or Both Roth 9. Projected Transaction !a&,cmudon Avg. Trans. Amt. $ 105 x Avg. # Trans./Day 18 = $ 1090 10. Third-Party Sender No Ifyes, has the cusmer been informed that they will need to provide a listing of their customers r n a weekly basis? Additional Notes APPROVED RELATIONS' AIPTERMINATED DATE INITIALS JetPay Signature Date First PREMIER Bank Signature Date 1, 2 . i, , a E RiVaR ‘,,. j1? DRIVER'S LICENSE NUMBER 04981 1005 EXPIRES 03 -31 -2012 HEMPHILL, WILSON WOOD JR PO BOX 674 . TYBEE ISLAND, GA 31328 -0674 SEX BIRTHDATE ISSUE DATE COUNTY M 03 -31 -1974 08 -13 -2009 025 HEIGHT WEIGHT CSC FEE RESTRICTIONS qt 5 -06 210 4 42 005.00 B CLASS ENDORSEMENTS TYPE C DUP ORGAN 1 J A `}/ Z