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Description
Transaction
Volume $
A

Your
Disc %
B

A * B
Total
C
Num. of
Transactions
D
Item
Rate
E
Trans
Fee
F
(D * E) +
(D * F)
Total
G

TOTAL
C + G
Qualified Std
  
   
 
VISA  
_____
  
_____
_____
_____
_______
$
Visa Debit  
_____
  
_____
_____
_____
_______
$
M/C  
_____
  
_____
_____
_____
_______
$
M/C Debit  
_____
  
_____
_____
_____
_______
$
Surcharges
  
   
 
Non-Qualified  
_____
  
_____
_____
_______
$
Rewards  
_____
  
_____
_____
_______
$
Other Charges & Fees
Batch Fee      
_____
  
_____
  
__________
Statement Fee
_____
  
__________
Monthly Minimum
_____
  
__________
Annual Fee/Dues
_____
  
__________
Reprogramming
_____
  
__________
Application Fee
_____
  
__________
Set-up Fee
_____
  
__________
Chargeback Fee
_____
  
__________
Voice Authorization
_____
  
__________
Other Fee's
_____
  
__________
 
TOTALS

Harley Financial Services * 5616 S 122nd E Ave, Suite N * Tulsa, OK 74146 * 800-266-9940 * Fax: 918-254-0713
Merchant card processing is provided by Columbus Bank and Trust Company, Member Bank for Visa and MasterCard
© 2008 Harley Financial Services - All Rights reserved