Electronic Bill Payer Sign-Up Form

Complete this form and mail, fax, or drop it off at the credit union.

Name: _______________________________________________________
Soc. Security #: _______________________________________________________
E-mail Address: _______________________________________________________
Postal Address: _______________________________________________________

City: ___________________ State: _____ Zip: ______________
Type of Account: _______________________________________________________
Account Number: _______________________________________________________
Co-owner of Account: _______________________________________________________
Credit Union Use Only
Routing #: ___________________________________________
CU Identifier: ___________________________________________
Date:
___________________________________________
Sender: ___________________________________________
Phone #: ___________________________________________
Fax #:
___________________________________________
E-Mail:
___________________________________________
Tier Group: ___________________________________________
Authorization
I authorize Tri-Point Federal Credit Union to post EBP transactions to the account indicated on this enrollment form. I further understand that the service fee(s) associated with the chosen plan will be directly debited from the same account. I understand that I am in full control of my account. If, at any time, I decide to discontinue the service, I will provide written notification to Tri-Point Federal Credit Union. My use of EBP signifies that I have read and accepted all of the terms and conditions of EBP service.

I understand that payments take an average of 5 business days to reach the payee, and that payments may be made electronically or by mail. Tri-Point Federal Credit Union is not liable for any service fees or late charges levied against me. I also understand that I am responsible for any loss or penalty that I may incur due to a lack of sufficient funds (NSF fee $20.00) or other conditions that may prevent the withdrawal of funds from my account.
Signature: ________________________________________
Thank you for signing up to use EBP service. Your start-up kit will arrive via U.S. Mail within 5 to 7 days.

 


National Credit Union Association Equal  Housing Lender Equal Opportunity Lender
We do business in accordance with the
Federal Housing Law and the Equal Credit Opportunity Act.