Automatic Payment Authorization Form - Yampa Valley Electric Association
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1YAMPA VALLEY ELECTRIC ASSOCIATION, INC.
PO Box 771218, Steamboat Springs, Colorado 80477
Phone 970-879-1160
Fax 970-879-7270
AUTOMATIC PAYMENT AUTHORIZATION
I authorize Yampa Valley Electric Association (YVEA) to process entries to my financial account or
credit card in the amount of my current monthly electric billing obligation. This authority will remain in
effect until written notice is given by either party to terminate the authorization. Notification of
cancellation shall be effective upon receipt of the written notice.
I agree to notify YVEA in writing if a change is made at my financial institution or to my credit card.
When a new credit card is issued, I will notify YVEA of the new expiration date.
Should an erroneous debit be made to my account, I authorize YVEA and my financial institution to
stop payment, reverse the entry, or make any adjustment necessary to my account to correct the
erroneous entry. A written notice explaining the changes will be sent to me by YVEA. I understand
that Yampa Valley Electric may assess a fee of $20 if my financial institution or credit card company
dishonors the electronic transaction.
APPLICANT: _______________________________________________________________________
MAILING ADDRESS: ________________________________________________________________
CITY: ___________________________________________ STATE: ______
ZIP: _____________
YVEA ACCOUNT NUMBER: __________________________________________________________
DAYTIME PHONE NUMBER: _________________________________________________________
************************************************************************************
NAME OF FINANCIAL INSTITUION: __________________________________________________
BRANCH OFFICE: ___________________________________________________________________
CITY: ____________________________________________ STATE: _____ ZIP: ______________
For bank drafts, a voided blank check must be included with this application
MASTERCARD or VISA NUMBER: ____________________________________________________
EXPIRATION DATE: _____________
EXACT NAME AS APPEARS ON CREDIT CARD: ________________________________________
ADDRESS WHERE CREDIT CARD BILLING IS SENT: ____________________________________
CITY: _________________________________________ STATE: _______ ZIP: _______________
_________________________________________________________
_______________________
APPLICANT SIGNATURE
DATE
REMEMBER TO SIGN THE FORM AND THEN FAX BACK TO YVEA WITH COPY OF CHECK (if using checking account)
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