Fiserv Merchant Account Application Form

The Professional Services team is honored to work with you as you begin the Implementation Phase of your new donor management system! Our team is here to support you through each step of your onboarding project.

The purpose of this form is to collect the information needed to initiate the application for your new payment gateway through CharityEngine. After submitting this form, your CharityEngine Professional Services point of contact will be available for any follow-up questions.

Your New Merchant Account for Payment Processing
Your responses to the questions below allow CharityEngine to initiate your organization’s Fiserv Merchant Account as well as ACH processing through CharityEngine, if applicable. CharityEngine will securely submit this information to initiate the Fiserv Merchant application. Upon submission, you will receive a request for electronic signature through CardPointe, a subsidiary of Fiserv. Once the electronic signature has been completed, Fiserv will initiate the underwriting and review for approval of a new merchant id to be used in your CharityEngine payment gateway.

To help us complete the Fiserv portion of the Payment Processing Setup, please follow these steps:

Complete all information on this secure webform & click Submit
Your CharityEngine Professional Service point of contact will connect for any follow-ups or questions

Important Notations:

Fiserv will not accept a PO Box. Please use a physical address.
Fiserv requires the organization to have a completed letter of determination from the IRS. Speak with your CharityEngine Professional Service point of contact if a letter of determination is not available as this can create delays for Fiserv underwriting and approval.

Thank you for your prompt and accurate review. Your time and attention to the following is appreciated in order to avoid processing delays with Fiserv.

Legal Name of Nonprofit

Entity Type

Organization Name

Doing Business As (DBA) Name

Tax Filing Name

Indicate if 501c3 or 501c4

Organization EIN Number

Organization Address Line 1

Organization Address Line 2

Organization Zip Code

Organization City

Organization State

Organization Phone Number

Organization Start Date

Principal Information

Owner/Principal of Organization

E-mail Address of Admin

Merchant Email

Merchant URL

Social Security # of Signing Executive

Upload Driver's License of signing executive

Organization's Financial Institution

Bank Name

Bank Location (City, State, & Zip)

ABA Routing Number

Bank Account Number

Bank Telephone

Upload Voided Check for settlement account

Processing Information

Average Monthly Credit Card Donation Amount:

Average Credit Card Donation Amount:

Number of monthly ACH Transactions

Monthly ACH Volume (In Dollars)

Acknowledgements

Merchant Account FeesI understand there are fees associated with the Merchant Account that are in addition to, and not associated with CharityEngine fees. These fees include, but are not limited to, credit card processing fees, statement fees, and PCI noncompliance fees.

ACH Set Up (if applicable)Once the Merchant Account has been approved through Fiserv, I agree to allow CharityEngine to use the above information for setting up ACH payment processing, if applicable.

ACH Processing (Bank Account and Electronic Check)

Nacha RequirementsI have reviewed and understand the NACHA requirements, including my responsibility, as a merchant accepting ACH transactions, to authenticate the identity of my donors. (information about NACHA authentication requirements available at https://www.nacha.org/system/files/resources/Authentication_0.pdf)