Bank Draft Action Form - 4 County Electric printable pdf download

Bank Draft Action Form

To make bill paying easier and more convenient, 4-County Electric offers its consumer/members a Bank

Draft payment option.

You will continue to receive a monthly bill. The bill will look like any other 4-County bill, except it will have

the words “Do Not Pay” printed in the Gross Amount Due portion of the bill. Your bill will be mailed to you

15 days prior to sending the draft to the bank. Your bank account will be drafted on the Due Date shown on

your 4-County bill. Bank Draft will take affect for the next billing month after request is received. Your billing

due date can be adjusted to fall after a certain date. Note: changing billing cycle could result in a longer or

shorter billing period while change is processed.

To sign up for Bank Draft or to make changes to your Bank Draft account; simply complete and sign the Bank

Draft information below and return it to your local 4-County Office. If you are signing up for Bank Draft or

changing your bank information, please attach a voided check to this form and include your account routing

number.

Bank Draft Information

Choose draft option:

New

Change

Remove

Please circle type of account:

Savings Checking

4-County Account #: _________________________________

Name (as shown on Bank Records): ____________________________________________________________

Name of Bank: _____________________________________________________________________________

Address of Bank: _____________________________________________ Bank Phone #: _________________

____________________________________

Checking / Savings Account #: _____________________________ Routing #:__________________________

Effective Date: ___________________ Draft on or after this date every month:_______________

I hereby authorize and confirm all information listed above.

Depositor’s Signature: _________________________________________ Date ________________________

CSR Signature: ___________________________________________ Date ________________________

It will not be necessary for 4-County Electric or anyone employed by it to sign such drafts or checks, and I agree

that your rights in respect to each such draft or check shall be the same as if issued and signed personally by me. I

further agree that you shall be under no obligation to furnish me with any special advice or notice in writing or

otherwise of the presentment or payment of any such draft or check or the charging of the same to my account. This

receive such notice. I

authorization is to remain in effect until revoked by me in writing, and until you actually

gree that you shall be fully protected in honoring any such draft or check. 4-County Electric is instructed to forward

this authorization to you. In order to qualify for any incentives I agree to remain on the Bank Draft program for

twelve (12) consecutive months or I forfeit promotional credit. I understand the promotional $25 credit will be

credited to my account. Members who have been on the Bank Draft program in the last twelve (12) months are not

eligible for promotion.

Bank Draft Action Form - 4 County Electric