Deluxe Provent ID Restoration Enrollment Form

Baltimore County Employees Federal Credit Union

Please fill out the form on your screen, print out and mail to the address listed below. The Credit Union requires an INK Signature for this application. We will not accept a faxed copy. This helps reduce account fraud.

Baltimore County Employees Federal Credit Union
23 W. Susquehanna Avenue
Towson, Maryland 21204

I have a Credit Union Checking Account and would like to enroll in the Deluxe Provent ID Restoration (basic service) and understand there is a monthly fee of $.99.*

I hereby authorize Deluxe to withdraw the monthly fee of $.99 from my share draft checking account.

Member Account Number:

Name:

Email Address:

Driver's License Number:

State of Issue:

Social Security Number:

- -

Mailing Address:

Second Address Line:

City:

State:

Zip Code:

Home Phone Number:

- -

Daytime Phone Number:

- - X

I understand that the Deluxe Provent ID Restoration (basic service) gives me access to a Certified Resolution Specialist (in the event I become a victim of identity theft), tools and tips to help prevent identity theft, occasional e-mail alerts and monthly activity reports, the ability to report identity theft and fraud concerns, and an online dashboard to store my personal information. The monthly fee of $.99 will be withdrawn from my share draft checking account on or about the 5th day of each month.

I understand that the Credit Union’s partnership with Deluxe Provent also provides additional fraud prevention services which include, but are not limited to: (1) Credit Monitoring at monthly cost of $2.99; (2) Internet Monitoring at a monthly cost of $2.99; and (3) Family Restoration at a monthly cost of $.99. Should I decided to enroll in any additional services, such as these, I understand that Deluxe will deduct those monthly fees from my share draft checking account as well.

This authorization for Deluxe Provent ID Restoration ( basic service) is to remain in full force and effect until Baltimore County Employees Federal Credit Union (BCEFCU) has received written notification from me (or any owner of the account) of its termination in such a manner as to afford BCEFCU and/or Deluxe a reasonable opportunity to act upon it.

Should I choose to terminate any of additional services I decided to sign up for, I understand it is will be my responsibility to contact Deluxe Provent directly to initiate such action.

X _______________________________________________________	____________________________
Member's Signature	Date

*The Deluxe Provent ID Restoration (basic service) is offered FREE of charge with no monthly fee for members enrolled to receive e-Statements of their checking account activity. Please consider signing up for e-Statements today!

Baltimore County Employees Federal Credit Union
23 W. Susquehanna Ave., Towson, MD 21204
410-828-4730

ABA/Routing Number: 2520-7575-7