CCBill Accounts Split Form

Sign and fax the completed form to 1-480-449-8823. E-mail: clientsupport@ccbill.com for assistance.

If you require assistance with this form, please contact accounting for clarification.

________ Split CCBill fees (fees are not split by default)

________ Split partner payout (payouts are not split by default)

Account number: Subaccount:

Email Address:

Name on main account:

Percentage:

Address:

City: State:

Zip Code: Country:

Tax ID (U.S. only):

Name of person(s) to split:

Account number (optional): Percentage:

Address:

City: State:

Zip Code: Country:

Tax ID (U.S. only):

Name of person(s) to split:

Account number (optional): Percentage:

Address:

City: State:

Zip Code: Country:

Tax ID (U.S. only):

Account Holder's Signature:

Date:

All requests need to be filled out and faxed to 1-480-449-8823. Please do not assume a change has been made unless you receive an email confirmation.

CCBill LLC, 2353 W. University Dr., Building A, Tempe, AZ 85281-7223, USA, Phone: 800.510.2859, Fax: 480.449.8823


August 2003	CCBL-5000-01