Menard Electric Cooperative
APPLICATION
AUTOMATIC PAYMENT PLAN
If you would like to sign-up for the automatic payment plan, then print and fill out the following form. Send form and a VOIDED CHECK or DEPOSIT SLIP to:
Menard Electric Cooperative
PO Box 200
NAME: ________________________________ SS#:________________
ADDRESS: ____________________________________________
CITY:______________________ STATE______________ ZIP __________
PHONE#_____________________
MAP LOCATION#______________________________(Upper Right Corner of Bill)
BANK NAME__________________________________________
BANK ACCOUNT#_____________________________________
TYPE OF ACCOUNT __Checking __Savings
I _______________________________ authorize Menard Electric Cooperative to draw monthly bank drafts through the automatic plan (ACH) on the account shown above for the payment of my electric bill in full and any other services I authorize. I understand that I may discontinue my participation at any time by notifying Menard Electric Cooperative in writing. Both Menard Electric Cooperative and the bank may terminate this agreement with ten (10) days written notice. I understand that Menard Electric Cooperative reserves the right to limit participation in this program to customers whose accounts are in good standing. I understand that the amount of my bill each month will be drafted on the 10th or next business day after. I understand that if funds are not available in my account for the draft to clear, there will be a charge posted to my Menard Electric Cooperative account, for NSF, and I will still be required to make full payment before the due date of the bill.
Signature of Applicant:_____________________________________________Date:_______