Oxy Electronic Funds Transfer (Eft) Enrollment Form printable pdf download

FUNDS TRANSFER (EFT) ENROLLMENT FORM

ELECTRONIC

NO MORE MAIL DELAYS - IT’S SAFE & SECURE - NO MORE LOST OR STOLEN CHECKS

*** IF YOU CHOOSE NOT TO PARTICIPATE IN EFT, DO NOT RESPOND AND WE WILL CONTINUE TO MAIL YOUR CHECK & DETAIL AS USUAL.***

IF YOU ELECT EFT AS AN ALTERNATIVE TO RECEIVING YOUR CHECK BY MAIL, YOUR PAYMENT WILL BE DEPOSITED INTO YOUR ACCOUNT ON THE 25th OF

EACH MONTH OR THE 1ST BANKING DAY FOLLOWING THE 25th.

***ALLOW 2 MONTHS FOR SET-UP***

IT’S EASY TO SIGN UP - FOLLOW THESE STEPS:

1. ACCOUNT INFORMATION

5. PLEASE SIGN AND DATE:

I (WE) AUTHORIZE OXY TO SEND MY (OUR) PAYMENT TO MY (OUR) BANK VIA ELECTRONIC FUNDS

___________________________________________________

TRANSFER (EFT) AND CONTINUE TO MAIL MY (OUR) DETAIL STATEMENT TO MY (OUR) ADDRESS.

TYPE OR PRINT YOUR NAME

SIGNATURE:________________________________________

DATE: _______________________

___________________________________________________

TELEPHONE NUMBER

TYPE OR PRINT YOUR NAME:____________________________________________________________

(IF ACCOUNT OTHER THAN INDIVIDUAL, INCLUDE YOUR TITLE, E.G., “TRUSTEE” OR “PRESIDENT”

___________________________________________________

LAST FOUR OF SOCIAL SECURITY OR TAXPAYER ID NO.

SIGNATURE:________________________________________

DATE: _______________________

___________________________________________________

TYPE OR PRINT YOUR NAME: ___________________________________________________________

YOUR OXY OWNER NUMBER

(IF ACCOUNT OTHER THAN INDIVIDUAL, INCLUDE YOUR TITLE, E.G., “TRUSTEE” OR “PRESIDENT”

___________________________________________________

6. TAPE AN ORIGINAL PREPRINTED VOIDED CHECK BELOW THAT INCLUDES YOUR NAME,

YOUR EMAIL ADDRESS

ACCOUNT NUMBER AND ROUTING NUMBER OR PROVIDE THIS SAME INFORMATION ON

LETTERHEAD FROM YOUR FINANCIAL INSTITUTION ALONG WITH THE ACCOUNT TYPE AND

2. PLEASE SELECT ONE ONLY

HAVE A BANK REPRESENTATIVE SIGN AS VERIFICATION

____ CHECKING or _____ SAVINGS

__________20_____

3. Check Detail:

_____ Continue to mail the check detail for this account

JOHN DOE ROYALTY

*** PLEASE TAPE ( DO NOT STAPLE) VOIDED CHECK HERE ***

_____ Do not mail the check detail for this account - I will

1234 REVENUE STREET

access this information at

MY CITY, STATE, 00000-0000

4. IS THIS FORM:

Pay to the order of: ______________________________________________$________________

_____ NEW Application

_____ CHANGE to previously submitted information.

TEMPORARY CHECKS AND/OR DEPOSIT SLIPS ARE UNACCEPTABLE

_____ CANCELLATION (Complete Step 1, sign and date below)

________________________________________________________________________________

My Bank

MEMO ________________________________

_________________________________

‘102201921’

‘1998978’

CANCELLATION SIGNATURE:____________________________________

Bank Routing Nbr

Personal Bank Account Nbr

DATE: ____________________

MAKE A COPY FOR YOUR RECORDS & MAIL FORM TO:

OXY, INC. ATTN LAND ADMINISTRATION

REVISED AUGUST 2016

P.O. BOX 27570, HOUSTON, TX 77227 - 7570

Oxy Electronic Funds Transfer (Eft) Enrollment Form

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