Authorization for enrollment in the Jay County REMC Automatic Payment Plan

Name:____________________________

Address:_________________________

City:____________________________

State:____ Zip Code:_____________

Phone#___________________________

REMC Account#____________________

Your Financial Institution:

_________________________________

Account#_________________________

Checking______or Savings_________

I authorize Jay County REMC to draw monthly bank drafts on my account shown above for the payment of my monthly electric bill. I understand that I can discontinue my participation in the APP by notifying Jay County REMC in writing. Both Jay County REMC and my financial institution may also terminate this agreement with ten (10) days written notice. I understand that Jay County REMC reserves the right to limit participation in the APP to customers whose accounts are in good standing.

Signature_______________________________

Date_____________________

Please mail this form to,

Jay County REMC
P.O. Box 904
Portland, IN 47371-0904

*Please attach a check marked "VOID" or include a deposit slip from your bank account.