PayGrip

This Affiliate Agreement ("Agreement"), is entered into this 13th day of February, 2014, by and between Paygrip, LLC, a Maine Corporation with an address of 75 Market Street, Suite 503, Portland, Maine 04101 ("Paygrip"), and the Referral Partner listed below ("Referrer") (or collectively, the "Parties"), whos e name, contact, and other information is as follows:

Full legal name of referring entity *
DBA name of referring entity
Full mailing address of entity *
Tax ID # *
Entity Type *
Primary contact name & title *
Phone *
Email *
Fax
Paygrip relationship manager & #

By checking this box you agree that you have read, understand, and accept the Affiliate Recital Instructions as outlined here

Affiliate Recital Instructions

IN WITNESS WHEREOF,
the parties hereto execute this Agreement as of the day and year first above written;

Signature of Referrer:

Draw your signature

Clear

Date: February 13, 2014

Form W-9

(Rev. August 2013) Department of the Treasury, Internal Revenue Service

Name (as shown on your income tax return) *
Business name/disregarded entity name, if different from above
Select appropriate federal tax classification *
If, Limited Liability Company, enter the tax classification
Other (see instructions)
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
Address (number, street, and apt. or suite no.) *
City, State, and ZIP code *
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 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 I 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 number to enter

Social Security Number
Employer Identification Number

Part II : Certification

Under penalties of perjury, I certify that:

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
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
I am a U.S. citizen or other U.S. person (defined below), and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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 3.

Signature of U.S. Person:

Draw your signature

Clear

Date: February 13, 2014

By checking this box you agree that you have read, understand, and accept the W9 General Instructions as outlined here W9 General Instructions

Affiliate Signup Form

Form W-9

Part I : Taxpayer Identification Number (TIN)

Part II : Certification