Request for Login Credentials to the iPayment Investor Information Center

In order to gain access to the iPayment® Investor Information Center and the information contained therein (the "Information"), you must represent and warrant to iPayment, Inc. that you are, or are acting on behalf of, (1) an existing holder ("Existing Holder") of iPayment, Inc.'s 9.50% Senior Secured Notes, due 2019 (the "9.50% Notes"), or (2) a bona fide prospective purchaser ("Prospective Purchaser") of the 9.50% Notes.

[FILL OUT AND SUBMIT (1) OR (2) AS APPLICABLE]

1. I am, or am acting on behalf of, an Existing Holder. The Existing Holder owns an aggregate principal amount of 9.50% Notes equal to approximately:
$

Company Name*

Address*

Phone*

Email Address*

Contact Name*


2. I am, or am acting on behalf of, a Prospective Purchaser.

Company Name*

Address*

Phone*

Email Address*

Contact Name*


IMPORTANT: Nothing contained herein, including the Information, is an offer by iPayment, Inc. or any of its affiliates or representatives to sell the 9.50% Notes or any other securities. You should discuss with your counsel and advisors before making any investment decisions. The Information is solely the information required to be provided to holders of the 9.50% Notes under iPayment's contractual obligations.  The Information does not purport to include all of the information that an investor may want to consider before purchasing any of the 9.50% Notes or any other securities.  Note that the Information may include material non-public information for purposes of United States securities laws.