CEC Customer Name: ___________________________________________
Service Address: _______________________________________________
City: __________________________ State: _______ Zip: _____________
CEC Account Number: ___________________________________________
I (we) hereby authorize Central Electric Cooperative, Inc. (CEC) and to automatically withdraw from my (our) account identified below the amount due on my (our) monthly billing statement for the electric account number listed above. I (we) authorize the Financial Institution below to accept such withdrawals initiated by CEC. The withdrawals shall be made from my (our) bank account on the due date indicated on each billing statement.
Financial Institution: ____________________________________________
Note: The routing and transit number is denoted by nine digits surrounded by |:
______________________________ ______________________________
Checking Acct # Routing & Transit #
______________________________ ______________________________
Savings Acct # Routing & Transit #
______________________________ ______________________________
Investment Acct # Routing & Transit #
This authorization is to remain in effect until CEC and the Financial institution have received written notification from me (or either of us) of termination in such time as to afford CEC and the Financial Institution a reasonable opportunity to act upon it (30 days). I (we) are aware of my (our) right to stop payment of a withdrawal by notifying the Financial Institution at any time up to 3 business days before the withdrawal date. If an erroneous withdrawal occurs and I (we) notify the financial institution of the error within 60 days of the issuance of my (our) financial institution's statement, the Financial Institution must investigate and resolve the error within 45 days of notification. If the error is not resolved within the first 10 days following receipt of my (our) notification, my (our) account shall be credited for the amount in question until the investigation is completed.
Telephone Number: ____________________ Date: _________________
Print Name: ____________________________________________________
Signature: _____________________________________________________
Additional Signature: ____________________________________________
(if required)
Mail application and voided check to:
Central Electric Cooperative
P.O. Box 846 For office use only:
Redmond, OR 97756 Rt#_______ Cycle#_______