Kosciusko REMC


	RECURRING AUTOMATIC PAYMENT AUTHORIZATION I authorize Kosciusko REMC and my financial institution to initiate withdrawals from my checking or savings account listed below or debit from my Visa, MasterCard, or Discover credit card listed below for payment of my electric bill. I may stop payment from my checking or savings account by notifying Kosciusko REMC at least three business days before my account is charged. I understand that I am responsible for advising Kosciusko REMC of any changes in my checking, savings, or credit card information, and may receive notification concerning my payment should it be declined. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. The authorization will remain in effect until I notify Kosciusko REMC in writing to cancel it. I understand that I must continue to report my monthly meter reading, either by phone or on-line at www.kremc.com.


	RECURRING AUTOMATIC CREDIT CARD PAYMENT AUTHORIZATION
	Name* First Name Last Name
	Address* City State Zip Code
	Daytime Phone*
	Email Address*
	Name on Card*
	KREMC Account #*
	Type of Card*
	Card Number*
	Expiration Date (i.e. 10/12)*
	Validation Code (last 3 digits of number on back of card)*

RECURRING AUTOMATIC PAYMENT AUTHORIZATION