Direct Deposit Form
Oil/Gas Revenue Payments
*Please note that ALL sections below must be completed.
Request Type (check one): New Enrollment Change Request Cancel
Owner Name or Company:
Owner Number: (If unknown, please notarize this form.) Tax Identification No.: (Last 4 Digits)
OR
Social Security No.: (Last 4 Digits)
Owner Mailing Address:
City: State: Zip:
Phone: Email:
Unless requested, check detail will not be mailed, as it is available at EnergyLink.com. Check this box to receive a paper copy of
check detail
Old Banking - for Change Requests Only New Banking
Bank Name Bank Name
Routing Number Account Number Routing Number Account Number
Account Type: Checking Savings Account Type: Checking Savings
REQUIRED: PLEASE PROVIDE A VOIDED CHECK OR OFFICIAL BANK LETTER THAT MATCHES THE OWNER NAME LISTED ABOVE.
I authorize ConocoPhillips Company and my financial institution to electronically deposit my payment to the account specified. This authority will remain in effect until I have filed
a new authorization. I understand that I can change my account or financial institution arrangement by completing a new Direct Deposit form available from ConocoPhillips Owner
Relations Unit.
Owner agrees to indemnify, release, defend, and hold harmless ConocoPhillips from and against all liabilities, claims, losses, costs, expenses, and damages of any kind
including direct, indirect, consequential and punitive asserted against ConocoPhillips directly or indirectly from or arising out of the changes authorized by this form.
Owner’s Signature: Date:
Title of Position (if Company):
Please submit the completed form along with a voided If Applicable, use this space for Notary:
check or official bank letter by mail, fax or email to: STATE OF
ConocoPhillips Company COUNTY OF
Attn: Station X
The foregoing instrument was acknowledged before me on this
315 S. Johnstone Ave.
day of , 20 .
Bartlesville, OK 74003-9956
Fax: 918.662.3513 (Seal)
RPAOwnerNameAndAddress@cop.com
Signature
For additional information, please contact Owner Relations per your last name or company:
A-F: call 918.661.0903 or email A-FORU@cop.com G-N: call 918.661.0904 or email G-NORU@cop.com
O-Z: call 918.661.0905 or email O-ZORU@cop.com
For detailed information on how we handle and protect your personal information/data, please refer to the ConocoPhillips’ Privacy Policy.
To send form electronically: Click to E-mail Form 17-582 F, 5-24
Direct Deposit Form
HOW WILL IT BENEFIT YOU?
Your payment will be placed in your financial institution account
on the day your check is currently mailed. You do not have to go
to your financial institution every month to make your deposit.
Your payment cannot be lost or stolen, and it will be placed in
your account even if you are away from home or the office.
If an error is made in calculating your payment, we will NOT take
funds out of your financial institution account. Recoupments of
overpayments will be against future payments. If future payments
are not available, we will request payment.
Your payment can be direct deposited in most types of financial
institutions (i.e., banks, credit unions, and savings & loans). Your
financial institution will inform you if they are unable to accept
direct deposit. EFT payments are only available for accounts
drawn within the United States.
Electronic payment statements are available at EnergyLink.com.
If you have never used EnergyLink, follow these steps to register:
1. Go to EnergyLink.com
2. Click New to EnergyLink? Sign Up Here
You will need your owner number and recent payment information
to complete registration. If you require assistance with registration,
go to EnergyLink.com/Contact
If you wish to receive your payment statement at your mailing
address, you can make that election on the Direct Deposit form.
