Blackbaud Merchant Services

This form gathers information so that the Diocese of Jefferson City can establish a Blackbaud Merchant Services account for a parish or other entity. This enables the parish/entity to receive donations or other contributions directly into its bank account.

Parish Information
Parish/Entity Name*
Please select your parish or organization from the list, note that it is organized by city.
Address*
Please provide a physical address (no PO addresses).

Street Address Address Line 2 City ZIP Code
Website
Principal Employee Information
Major credit card brands - including Visa, MasterCard, and American Express - require that we collect the following information about a principal employee with signatory authority at your organization.
Name*
First Middle Last Suffix
Date of Birth
MM slash DD slash YYYY
Social Security Number or ITIN*
Email*
Phone*
Home Address*
Home address required, not a post office box.

Street Address Address Line 2 City ZIP / Postal Code
Financial institution information
Please list the information below that pertains to your parish's financial institution (bank).
Name of Financial Institution*
Bank Routing Number*
Enter your routing number; this is a nine-digit number found at the bottom left of your institution's checks.
Bank Account Number*
Enter your routing number; this is usually found at the bottom of your institution's checks, to the right of your routing number.
Federal Employer Identification Number (FEIN)*
Is this account a checking or savings account?*
- Checking
- Savings
Validation and access to Merchant Services Account
Please provide a mobile number to which the user name and password for the Blackbaud Merchant Services Account can be texted. This should be a staff member or someone authorized by the parish to manage parish finances/bookkeeping.
Name associated with mobile number*
First Last
Mobile Phone*
Upload verification*
Please upload a voided check, bank statement, or bank letter so that your information can be verified. You can scan these items or take a photo.
Accepted file types: pdf, jpeg, tif, png, Max. file size: 1 MB.
Authorization
Affirm Authorization*
- I hereby authorize Blackbaud, Inc., hereinafter called COMPANY, to initiate credit entries (and/or debit adjustments for any negative balance including refunds/chargebacks or credit entries made in error) to my account indicated below at the depository financial institution named above, hereafter called DEPOSITORY, and to credit the same to such account. The authorization is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. Please Note: Written credit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.
Provide your eSignature below by typing your name.*
Comments
This field is for validation purposes and should be left unchanged.

Blackbaud Merchant Services

Parish Information

Principal Employee Information

Financial institution information

Validation and access to Merchant Services Account

Authorization

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