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PAYMENT SERVICE NETWORK, INC. SERVICE AGREEMENT SCHEDULE W [Complete Sections I. II and IIII I. CORPORATE OFFICE INFORMATION Contact Name: I Michele Lindau I Business Legal Name: I City of Hugo Address: 14669 Fitzgerald Ave N Telephone: 651-762-6315 Email: I mlindau@ci.hugo.mn.us City, State, ZIP: I Hugo, MN 55038 Fax: Website: I http://www.ci.hugo.mn.us II. LIST OF ADDITIONAL PROPERTIES ACCOUNTS ORSERVICES: (Please use a separate sheet if needed or an Excel spreadsheet if possible.) Total Service Description Number or Property Name Potential Payers Address Tax ID Last 4 Digits of (If different from Corporate above) REQUIRED Checking (Include: Street Address, City, State, ZIP) Account Contact Person (for this account, if different from above) Email (for this account, if different from above) Phone Number (for this account, if different from above) 100 Permits III. DEPOSITING AND INVOICING INSTRUCTIONS AND REQUEST FOR VOIDED CHECKLI: • Check the box as to how you want PSN to debit its fees from your bank account(s). X PSN should invoice and take its fees from the same bank account(s) to which it is depositing funds ❑ PSN should invoice and take its fees from a different bank account than the one to which it is depositing funds. Last 4 digits of bank account from which PSN takes fees: _ (please provide voided check, no deposit slips allowed) • Attach to this Agreement, an actual voided check(s) for the bank account that PSN will deposit funds into and, if applicable, a voided check of the account from which PSN will debit its fees. It must be a printed voided check and not a starter check, a deposit slip or other substitute. If it is not possible to attach a voided check(s), then you can attach a letter from your bank(s) on bank letterhead that is legally signed by a bank representative, verifying your checking/savings account number and the bank's routing number. NOTE: If using more than one bank account, mark each voided check to clearly identify which account it represents. • In order to debit fees from your account(s), you may have to inform your bank(s) that Payment Service Network (PSN) is an approved vendor. Once you have signed and returned this Agreement, PSN will provide you with its official NACHA vendor number to provide to your bank(s). Note: Bank interchange rates are subject to change; therefore, this quote is valid for 15 days from date of issue. 8 Payment Service Network, Inc. 1 2901 International Lane, Madison WI 53704 1 www.PaymentServiceNetwork.com