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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (DEBITS) |
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(Fill out form and attach a voided check. Return to your local WIPCO office.) |
| I authorize Western Iowa Power Cooperative, hereinafter called COMPANY, to initiate withdrawals and to initiate, if necessary debit entries and adjustments for any credit entries in error to my account at the financial institution named below for payment of my monthly bills. |
| I understand that three or more payments in a 12 month period resulting in overdraft of my account my result in termination of the Direct Payment plan. This authorization will remain in effect until COMPANY has received written notification from me of its termination in such time and manner as to afford the COMPANY and my financial institution a reasonable time to act on it. |
| FINANCIAL INSTITUTION _________________________________TRANSIT / ABA NO.________________________ |
| CITY______________________________ STATE ____________________ ZIP ________________________ |
| ACCOUNT NO. _____________________________ ( ) Checking ( ) Savings (select one) |
| Amount of payment: Monthly Amount Due Purpose: Electric Bill |
| Payments to begin: Allow 30 days to be made on the 24th day of each month. |
| Acct # to Credit:____________________________ Expiration date (if known)_______________________ |
| Account Holder Name: ______________________________ ID No.:_________________________________ |
| Signature: ________________________________________ Date: ___________________________________ |