CheckFree Electronic Bill Payment - Consumer Enrollment Form
Important: Please print the form below, (you can complete it online first or print it first and then complete it using block letters) include an imprinted voided check from your designated checking account(s). If more than one bank account, please designate which account should be used to debit your service fees. Return via U.S. Mail to the address on the right:
CheckFree Payment Services P.O. Box 2168, Columbus, OH 43216-2168
Primary Applicant
Social Security Number: (Your confidential Subscriber ID)
Mother’s Maiden Name: (For security)
Date of Birth:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip Code:
Daytime Telephone Number:
Evening Telephone Number:
Fax Number:
Co-Applicant - Additional Authorized User - Optional
Service Information
I will be using electronic bill payment using: (choose only one of the options below)
Quicken for Windows: '98 (QIW07/000/519) '99 (QIW08/000/519) 2000 (QIW09/000/519) 2001 (QIW10/000/519)
I authorize my financial institution to debit the account(s) indicated on the attached voided check(s) for payments I request through CheckFree and for the appropriate monthly bill payment service fee. I understand that the service fee will be debited monthly from the designated account until I provide written notification to CheckFree to cancel the account. My first use of the service signifies that I have read and accepted all the terms and conditions of the CheckFree service.
Primary Applicant Signature:
Date:
Co-Applicant Signature:
CheckFree must have your signature on this form to process this information. Note: Save a copy of this form for your records.