Automatic Payment Plan information

Bartholomew County REMC AMPS Authorization Form Fax to: 812-372-2112 or mail to P.O. Box 467, Columbus, IN 47202

Name:
Street Address:
City:	State:	Zip:

REMC Account Number (s):

Please automatically withdraw from Checking/Savings Account
Bank Routing Number:
Checking/Savings Account Number:
Bank Account Name:
If using this method please include a copy of a voided check or deposit slip.

Please automatically charge my Credit/Debit Card
Card Type (MasterCard, Visa, Discover):
Credit Card Number:		CV Code:
Cardholder's Name:		Exp. Date:
I authorize Bartholomew County REMC to draw a monthly draft on my bank account or process a charge to my credit card account as shown above for the payment of my monthly bill. I understand that I can discontinue my participation in AMPS by notifying the REMC in writing ten (10) days prior to the next payment date. REMC, the Bank, and the Credit Card Company may terminate this agreement at any time. I understand that the REMC reserves the right to limit participation in AMPS to customers whose accounts are in good standing. If funds are unavailable at the time of transfer, the amount of the payment will be charged back to my account and I will automatically and immediately be terminated from this program. A $25 fee will be charged to my account if these funds are not available at the time of transfer.
Signature:		Date:
(For Office Use Only): Employee Initials______ Date Posted:____/____/____
NOTE: Your bill amount will be deducted from your checking/savings account or charged to your credit card account as requested by this form. Your bill statement will show that your payment will be automatically paid by displaying the message, "AMOUNT WILL BE AUTOMATICALLY DEDUCTED" Please allow four to six weeks for the plan to be implemented. The transaction will show as SEDC Utility on your credit card statement.