Please fill out this form so we can begin the process of creating a solution to fit your specific needs. 
This form will be sent to Aquracy, LLC when you click on the "Submit" button at the bottom of the form. 

All fields marked with a * are required.

Section 1: General Organization Information
Organization Name	*
Contact Name	*
Email Address	*
Business Description (Ex. Organization type, industry, Market segment)
Address	*
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Wales Washington West Virginia Wisconsin Wyoming
Zip Code
Phone Number	*	Ext.
Fax Number		Ext.
Are you currently using a Payment (Remittance) Processing System? (If Yes, please provide hardware model and software supplier)	Yes No	Hardware model
		Software supplier
Do you currently use a lockbox provider? (If Yes, please provide costs of the lockbox provider)	Yes No  Cost $      Per  Week Month Year Other
Decision Date	Now 60 Days 6 Months 1 Year Over 1 Year

Section 2: Payment (Remittance) Processing Information

Please provide information about the volume of checks & associated documents you receive

Number of transactions per month
Note: A transaction is an individual payment.  It consists of a set of distinct coupon(s) and/or check(s).
Average transactions per day
Peak transactions per day
Is volume growing?	Yes No
Provide monthly growth percent:	%
Average number of transactions per hour your organization processes
How many different types of remittance documents do you use?	1 2 3 4 5       I have more than five different remittance documents.
Note: Different remittance types typically use separate coupons or have different scan line definitions.

---

Please provide the hours and/or people per day required to perform the following tasks.
 

Note: Not all tasks will be performed by your organization
Task	Hours/Day	People/Day
Mail opening and sorting
Data Entry
Endorsing checks (hand stamp)
Balancing deposits
Encoding checks on transport
Microfilming / Imaging
Identifying exceptions
Creating deposit reports
Copying checks
Other:
Total Number of People
Productive Hours per Day	6 6.5 7 7.5 8
Are all your checks deposited every day?	Yes No
How much does your bank charge for a deposit?	$
What do you use for your accounting / back end / host system?

Section 3: Remittance Document Details

Document 1

Please provide the percentage mix of transactions for this remittance document

Transaction Type	Percentage Mix
Singles (one coupon and one check)	%
Check Only (no coupon)	%
Multiples (one or more coupons and one or more checks)	%
Coupon Only (no check)	%
Check & List (check only with a list of associated accounts)	%
Other:	%
Average transactions per day for these remittances

Please provide data about the coupon's scan line
Note: The scan line consists of a printed line of data that identifies information about the remittance
Does the coupon have a scan line?	Yes No
What is the scan line font?	OCRA OCRB E13B Barcode

Please describe the fields that make up the scan line or the fields that should be on the scan line of a new coupon
Field Name	Field Length	Data Type (A alpha / N numeric)
Please describe specific rules, field validations, additional data entry, special functions etc needed to process these remittance documents.