billpay-application

Print Reset Save Fidelity BillPay® ApplicationCustomer InformationOwner’s NameFirst Name Middle Name Last NameDate of birth (mm/dd/yyyy) Account number Ext.Joint Owner’s name (if any)Social Security number: Owner Joint OwnerOwner’s phone numbers: Evening DaytimeE-mail addressFidelity BillPay® enables you to pay bills electronically through the Internet or eligible mobile devices asdetermined by Fidelity. The service is available to brokerage accounts with individual, joint, estate, ortrust registrations.The Fidelity BillPay service is free of charge for all customers. To apply for the Fidelity BillPay service, complete,sign, and return this form to the address below. Or apply for the service online at Fidelity.com.This service is solely for personal, family, or household purposes, and not for any business or commercialpurposes. If you have any questions, please call us anytime at 800.544.5703. 1 Service AgreementAll account owners must sign below. I/We hereby understand that Fidelity Brokerage Services LLC isthe provider of the Fidelity BillPay service. By signing below, I/we hereby understand that and/or agree to:(1) authorize Fidelity Brokerage Services LLC to post bill payment transactions originating from the FidelityBillPay service to my/our Fidelity Account; (2) this Fidelity BillPay Application is subject to review andacceptance by the provider of the service; (3) the Fidelity BillPay service is subject to the Fidelity BillPayService Agreement, which is incorporated into this application by reference and made a part hereof as suchterms are currently in effect and as they may be amended in the future; (4) I/we will be sent the Fidelity BillPayService Agreement after I/we submit this application, and any use of the Fidelity BillPay service confirms my/our agreement to the Fidelity BillPay Service Agreement; (5) I/we may terminate the Fidelity BillPay serviceat any time by calling customer service or sending a written termination request using the phone numberand address provided in the Fidelity BillPay Service Agreement (the Fidelity BillPay Service Agreement is alsoavailable at Fidelity.com or by calling 800.544.5703); and (6) I/we hereby authorize the provider of the service tohonor any instructions entered through the Internet using my/our customer identification number and personalidentification number.SIGNATURE OF OWNER Date (MM/DD/YYYY) SIGNATURE OF JOINT OWNER Date (MM/DD/YYYY) X XFidelity BillPay and Fidelity Account are registered service marks of FMR LLC and services of Fidelity Brokerage Services LLC, Member NYSE, SIPC.439387.6.0 PO Box 770001 BP-OSCAPP-0313 Cincinnati, OH 45277-0013 1.773057.106016320301