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AUTHORIZATION FORM
Yes, I want to participate in the AUTOMATIC PAYMENT PLAN
Name (s) as shown on your bill:_______________________________
Account Number:_______________________________________________
Billing Address:_______________________________________________
City:_______________ State:_____ Zip: ______
Home Phone:_____________ Work Phone:_____________
Your Financial Institution:______________________
Financial Institution Address:__________________________
City:_______________ State:_____ Zip: ______
Your Financial Routing Number:_______________
Checking Account Number:_______________
Please enclose a blank check from your checking account. Write VOID across it and DO NOT
SIGN IT.
Bayfield Electric Cooperative has the right to cancel my use of the Automatic Payment Plan.
I will write to Bayfield Electric Cooperative if I decide to cancel my use of the Automatic Payment Plan.
Account Holder (s):_______________________________________________
Signature (s):_______________________________________________
Date:_______________
NOTES:
(1) If the account is in two names, both account holders must sign above.
(2) If you currently submit a monthly reading to us you MUST continue to do so either by mail or call it
in using our 1-800-278-0166 toll free number.
If you have any questions, please call Bayfield Electric Cooperative at 715-372-4287 or 1-800-278-0166 or email us.
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