DDA CHANGE FORM. STEP 1: CHANGE INFORMATION (Required) Please check all changes that apply, and complete the sections indicated.

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1 DDA CHANGE FORM Thank you for notifying us of the recent change to your business. We re happy to process the bank account (DDA) change you requested for your payment processing account. The information below will help guide you through the steps, so that we can process your request. STEP 1: CHANGE INFORMATION (Required) Please check all changes that apply, and complete the sections indicated. DBA and/or Corporate Name, (Complete - Sections 1, 2, 3, 4, 5, 7, 8 & 9) Do not use this form for DBA/ changes. Contact Merchant Support at merchantsupport@mindbodyonline.com. DDA: (Complete - Sections 1, 2, 7 & 8 ) and include your DBA & Merchant ID at the bottom of each page Add or Remove an Helpful information for completing each section: BUSINESS INFORMATION THE ENTIRE SECTION MUST BE COMPLETED. TAX INFORMATION (Substitute form W-9) For detailed instructions on completing the W-9 Form, please refer to your tax return or visit gov/pub/irs-pdf/iw9.pdf. This information is the same as the information used to file taxes for your business. It s important that this information be correct as it will be used for the required IRS 1099K reporting. BUSINESS NAME CHANGE Enter the new DBA and/or Corporate Name and address information. OTHER ADDRESS Please complete if Mailing, Billing, Chargeback or Copy Request is different than DBA/Corporate Address. PRINCIPAL INFORMATION Include all owners with 25 or greater ownership. If there are none then provide the information of the of the business. One person should be identified as the. The must be a Beneficial Owner or the with day-to-day control of the Business. REMOVE CURRENT OWNER /AUTHORIZED SIGNER Complete this section if you are removing a Current Owner or. DDA CHECKING ACCOUNT CHANGE Please provide any changed banking information for your business. If your banking information has not changed, this section is not required. SIGNATURE INFORMATION Must be signed by the principal or authorized signer listed in Section 5. If principal has changed, the previous principal does not sign. If adding additional principals or authorized signers, the current principal or authorized signer must sign. INTERMEDIARY BUSINESS / OWNER Complete if there are business and/or business owners with 25 or greater ownership. Send your completed form to MINDBODY at merchantsupport@mindbodyonline.com For questions, contact MINDBODY at STEP 2: We review your request. Once we receive your completed form, we will review for any missing information. We may contact you if additional information is required. If additional information is not provided within 8 business days, the request will be cancelled. You will receive an notification when your change is complete.

2 BUSINESS INFORMATION Merchant Identification Number (MID): DBA Name (Current): Effective Date of Change: Corporate Name (If different than DBA Name): DBA Phone #: Contact Name: DBA Fax #: DBA Address 1 ( PO Box): DBA Type: Mobile Phone # : Year Established: Length of Current Ownership: Year DBA Address 2 ( PO Box): Country of Primary Business Operations: Business Country of Formation (Headquartered): (mark "" if N/A) Special Requirements Month Is the company an Embassy? Annual Revenue: Is the company a Money Services Business? Does the company operate a privately owned, non-bank ATM? Is the company a n-profit/n-government Organization? Does the Company have the ability to issue Bearer Shares as an ownership stake in the Company? (required if country of formation is outside of the US) If yes, does the company receive funds or card payments internationally in the excess of $25,000 annually? TAX INFORMATION (THIS SECTION MUST BE COMPLETED FOR ALL UPDATES) Business Type: Sole Proprietor Public Corp. Closely Held Corp. Sub S Corp. Professional Corporation Limited Partnership Government Tax Exempt Organization Other (Assn/Estate/Trust) Limited Liability Company Tax Classification (D=disregarded entity, C=corporation, P=partnership) If LLC, please indicate if D, C, or P Business Name (As s shown on your business income tax returns. For Sole Proprietors, this should always be the owner s name) Business TIN #/ or EIN (Employer Identification #): BUSINESS NAME CHANGE - this is a bank account update form, if you also need to update your DBA/ownership please merchantsupport@mindbodyonline.com. Full Corporate Name: DBA Business Name (New): DBA Address 1 ( PO Box): Corp Address 1: DBA Address 2 ( PO Box): Corp Address 2: DBA Type: Corp Type: OTHER ADDRESS (Please complete if Mailing, Billing, Chargeback or Copy Request is different than DBA/Corporate Address.) this is a bank account update form, if you need additional updates, please merchantsupport@mindbodyonline.com. MAILING BILLING CHARGEBACK COPY REQUEST Location Name: Contact Name: Fax Number: Page 2 of 7

3 PRINCIPAL INFORMATION - Include all owners with 25 or greater ownership. If there are none then provide the information of the of the business. One person should be identified as the. The must be a Beneficial Owner or the with day-to-day control of the Business. this is a bank account update form, if you need additional updates, please merchantsupport@mindbodyonline.com. PRINCIPAL 1 INFORMATION - SECTION Home ITIN #: Issuing Expiry Does the business have other Principal (owners) who have a 25 or greater ownership?) (If yes, add all in the below sections) PRINCIPAL 2 INFORMATION - SECTION Home Issuing Expiry PRINCIPAL 3 INFORMATION - SECTION Home Issuing Expiry Page 3 of 7

4 PRINCIPAL 4 INFORMATION - SECTION Home Issuing Expiry REMOVE CURRENT OWNER / AUTHORIZED SIGNER Complete only if changing DDA CHECKING ACCOUNT CHANGE Deposit Account DDA Account Number Number Billing Account Check here if same as Deposit Account DDA Account Number: Number: Chargeback Account Check here if same as Deposit Account DDA Account Number: Number: If you also process through Fusebox and would like to update your bank account information on the Gateway please complete the information below. This information is for the billing of Elavon Hosted Payment Fusebox Gateway service fees only. If you do not use Elavon as your Processor/Acquirer, you will need to notify the appropriate parties so the changes are made to their system as well. Fusebox Billing Account Check here if same as Deposit Account Site ID: DDA Account Number: Number: DEBIT/CREDIT AUTHORIZATION AND PAYMENT AGREEMENT: MERCHANT HEREBY AUTHORIZES ELAVON, IN ACCORDANCE WITH THE MERCHANT PROCESSING AGREEMENT (THE TERMS OF ELAVON S CURRENT TERMS OF SERVICE AND MERCHANT OPERATING GUIDE BEING EXPRESSLY INCORPORATED HEREIN AND AGREED TO BY MERCHANT), TO INITIATE DEBIT/CREDIT ENTRIES TO MERCHANT S BUSINESS CHECKING ACCOUNT AS INDICATED. THE AUTHORITY IS TO REMAIN IN FULL FORCE AND EFFECT UNTIL (A) ELAVON HAS RECEIVED WRITTEN NOTIFICATION FROM MERCHANT OF ITS TERMINATION IN SUCH MANNER AS TO AFFORD ELAVON REASONABLE OPPORTUNITY TO ACT ON IT; AND (B) ALL OBLIGATIONS OF MERCHANT TO ELAVON THAT HAVE ARISEN HAVE BEEN PAID IN FULL, INCLUDING, BUT NOT LIMITED TO, THOSE OBLIGATIONS DESCRIBED IN THE MERCHANT PROCESSING AGREEMENT. THIS AUTHORIZATION EXTENDS TO SUCH ENTRIES IN SAID ACCOUNT CONCERNING LEASE, RENTAL, OR PURCHASE AGREEMENTS FOR POS TERMINAL AND/OR ACCOMPANYING EQUIPMENT. NOTE: If you receive funding directly from American Express ( ), Discover ( ) and/or Diners Club ( ), you will need to notify them of your change, as each will need to make the appropriate changes to their system as well. Page 4 of 7

5 SIGNATURE INFORMATION By signing, I confirm that the information given in this form is true, complete, and accurate. I understand that withholding or providing false information may result in delayed request, denial of request, or account closure. Owner / Officer Signature X Printed Name Title Date Owner / Officer Signature X Printed Name Title Date AGENT BANK (Owner/Officer and Bank Signature Required) Rel Pend Reason Approved Keyed Validated INTERMEDIARY BUSINESS / OWNER - this is a bank account update form, if you need additional updates, please merchantsupport@mindbodyonline.com. Does the business have other investors (businesses) who have a 25 or greater ownership stake? (If yes, complete section 9) (Include all additional intermediaries with 25 or greater ownership) INTERMEDIARY BUSINESS / OWNER 1 INFORMATION - SECTION Intermediary Business Issuing Expiry Page 5 of 7

6 ADDITIONAL INTERMEDIARY BUSINESS / OWNER (Include all additional intermediaries with 25 or greater ownership) INTERMEDIARY BUSINESS / OWNER 2 INFORMATION - SECTION Intermediary Business Issuing Expiry ADDITIONAL INTERMEDIARY BUSINESS / OWNER (Include all additional intermediaries with 25 or greater ownership) INTERMEDIARY BUSINESS OWNER 3 INFORMATION - SECTION Intermediary Business Issuing Expiry Page 6 of 7

7 ADDITIONAL INTERMEDIARY BUSINESS / OWNER (Include all additional intermediaries with 25 or greater ownership) INTERMEDIARY BUSINESS OWNER 4 INFORMATION - SECTION Intermediary Business Issuing Expiry Page 7 of 7