ACH OEI Direct Deposit Form

Owner's Relations

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)

Owner Name *

Owner Code *

Select One *

Checking Account Savings Account

Please indicate below the depository Financial Institution. I (we) acknowledge that the authority will remain in effect until I have (or either of us) cancelled it in writing and that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Please Attach a Voided Check *

Max file size: 20MB

Financial Institution *

City *

State *

Zip *

Routing Number *

Account Number *

Name(s) On Account *

This authorization is to remain in full force and effect until Omimex has received written notification from me (or either of us) of its termination in such time, and in such manner as to afford Omimex and Financial Institution a reasonable opportunity to act on it.

Name(s) *

Last 4 of TIN or SS# *

Date *

Signature *

Phone Number *

AUTHORIZATION FOR STATEMENTS VIA E-MAIL
Omimex is now requiring ACH advice and Revenue Summary Statements to be e-mailed for those persons having their revenues paid via ACH. Joint Interest Billings and Accounts Receivable Summary Statements can be sent via e-mail and/or postal mail. Please fill out the following section to indicate your choice of e-mail only or e-mail and postal mail for JIBs and ARS Statements (WI owners only).

Statement Type:

Joint Interest Billing

E-mail Address *

Select One *

E-mail Only Postal Mail Only

ARS Statement

E-mail Address *

Select One *

E-mail Only Postal Mail Only

Revenue Statement/ACH Advice

E-mail Address *

(e-mail only required for ACH)

If you have any questions, please call 817-460-7777.

IMPORTANT NOTE: Omimex has had ongoing problems sending e-mails to Charter e-mail addresses. If you have a Charter e-mail account, please open a new account (there are many free ones such as hotmail, yahoo mail, or gmail from google) to ensure that you receive your statements.

Submit

If you would like to print and fill out, click here
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Please attach a voided check and send completed form to:
Omimex Energy, Inc., 7950 John T. White Rd, Fort Worth, TX 76120
OR fax completed form to 817-460-1381
OR e-mail completed form to revenergy@omimexgroup.com