ELECTRONIC FUND TRANSFER PAYMENT
ELECTRONIC FUND TRANSFER PAYMENT
AUTHORIZATION FORM
This is my (our) authorization to my bank, named below, to deduct from my checking or savings account (specified below) and pay to Withlacoochee River Electric Cooperative, Inc., (WREC) the amount of my monthly electric service bills. This authorization shall continue until written notice of cancellation is received by either the bank or Withlacoochee River Electric in such time as to afford a reasonable opportunity to act on it.
WREC ACCOUNT NUMBER: _____________________________________________________
NAME AS IT APPEARS ON WREC BILL: ___________________________________________________________
Telephone Number: ___________________________ Alternate Telephone Number: _______________________
NAME AS IT APPEARS ON YOUR BANK ACCOUNT:_________________________________________________
|Checking Account No. _____________________ |Savings Account No. _________________________ |
BANK NAME: ______________________________________ BRANCH: __________________________________
BANK'S MAILING ADDRESS: _________________________________________________________
_________________________________________________________
_________________________________________________________
PLEASE SIGN YOUR NAME(S) EXACTLY AS YOU DO ON YOUR CHECKS
Signed ___________________________________________Signed______________________________________
Date __________________________________
**IMPORTANT: BE SURE TO ENCLOSE A BLANK VOIDED CHECK SO WE MIGHT OBTAIN NECESSARY ROUTING AND ACCOUNT NUMBERS.
1
**************ELECTRONIC FUND TRANSFERS CAN ONLY BE ACCOMPLISHED WITH BANKS IN THE UNITED STATES****************
MAIL TO: Withlacoochee River Electric Cooperative, Inc.
Attn: Customer Service Dept.
P. O. Box 278
Dade City, FL 33526-0278
*** TO BE COMPLETED BY WREC ***
TRANSIT/ABA NO. ________________________________________
BANK ACCOUNT NO. ________________________________________
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