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Jackson County REMC
E-Z Pay Plan
Authorization Form
(please print)
Name
_____________________________________________________________________
Address____________________________________________________________________
City
__________________________________________ State ______ Zip
____________
REMC Account Number
______________________________________________________
Daytime
Phone______________________________________________________________
Bank
Name_________________________________________________________________
Bank City & State
___________________________________________________________
Bank Account Number
_______________________________________________________
Please check one:
Checking Account ________
Savings Account ________
I authorize Jackson County REMC to
draw monthly drafts on my bank account, shown above, for the payment of my
monthly electric bill. I understand that I can discontinue my participation in
the E-Z Pay Plan by notifying Jackson County REMC, and my bank may also
terminate this agreement within ten days of written notice. I understand that
Jackson County REMC reserves the right to limit participation in the E-Z Pay
Plan to customers whose accounts are in good standing.
Please include a
voided check or deposit slip with this request.
Be sure all
information is completed.
Please check one box:
c
Yes, I want a meter, if possible, that will
automatically transmit readings for
billings on the 17th of each month.
c
No, I want to continue sending in my own meter
readings.
Signature
____________________________________________ Date ______________
Mail your completed enrollment form
to:
Jackson County REMC
Attn: Billing Department
PO Box K
Brownstown IN 47220-0311
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