|Ark Valley Electric Cooperative , Inc.
Authorization Agreement for Automated Payments
|I (we) hereby authorize Ark Valley Electric Cooperative, Inc., and the financial institution named below to initiate debit entries to my bank account indicated below, on or about the last day of each month for the monthly bills on my (our) electric service account(s).
BANK NAME _____________________________________
BANK ADDRESS __________________________________
BANK ROUTING NO. ________________ BANK ACCT. NO. ________________
I understand that if the account being charged for my electric bill is insufficient to pay my bill, I remain liable and responsible to timely pay my bill, including any late fees that may apply.
I further understand that I may revoke this authorization to debit my above account for my electric bill at any time. If I revoke this authorization, I understand that I must give written notice of such revocation to Ark Valley Electric.
This authority is to remain in full force and effect until Ark Valley Electric has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Ark Valley Electric a reasonable opportunity to act on it.
UTILITY ACCT. NUMBER(S) _______________________________
NAME ON UTILITY ACCOUNT _____________________________
JOINT SIGNATURE ____________________________
|Please mail a voided check or a deposit slip along with the agreement to:
Ark Valley Electric, PO Box 1246, Hutchinson, KS 67504
When the Automatic Payment Plan becomes active for your account, it will be noted on your bill.