Fillable AutoPay Authorization Form Credit/Debit Card

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AutoPay Authorization Form Credit/Debit Card

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The AutoPay Authorization Form Credit/Debit Card form is 1 page long and contains:

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AutoPay Authorization Form – Credit/Debit Card
1LJKWLQJDOH6WDIILQJ,QF is pleased to offer AutoPay, a free automatic payment option to its valued customers. With AutoPay, yourpayment is automatically
withdrawn from your credit or debit card each billing cycle. AutoPay makes bill paying easy and avoids the chance of late payment fees.
Here’s how AutoPay works: Your regular bill will show services rendered, amount owed and the pay
ment date due. On the due date, about 15 days after
the bill is mailed, t
he amount owed will be automatically deducted from your card account. No stamps, checks, or envelopes are needed.
You will still receive your bill by mail, giving you the opportunity to inspect all charge
s and report any concerns before the bill is paid from your card
account. A recor
d of your AutoPay payment will be noted on your next PRQWKO\ bill, as well as on any
regular statements you may receive
from
your card company.
Here’s how you can sign up for AutoPay:
¾ Complete and sign this form
¾ Return all information to the address shown to the right.
Questions? Please call  ([WWRVSHDNZLWK1LJKWLQJDOHV'LUHFWRURI%LOOLQJ.
Please print or type all entries.
1LJKWLQJDOH6WDIILQJ,QF
Customer Name (As shown on Card Account/Statement)
Contact Phone Number
Customer Billing Address (As shown on Card Account/Statement)
E-mail Address
CXVWRPHU Account Number (,I$SSOLFDEOH
Maximum Draft Amount Allowed – (THIS MUST
FILLED OUT WITH $ AMOUNT TO PROCESS)
To Pay By Card VISA MasterCard No other cards accepted at this time.
Card #
Expiration Date
Bank or Credit Union name:
__________________________________ ____________
Customer Signature Date
Last Revised: 0D\
Mail To:
1LJKWLQJDOH6WDIILQJ,QF
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6DYDQQDK*HRUJLD
By signing above, I/we hereby authorize 1LJKWLQJDOH6WDIILQJ,QF to deduct funds from my designated credit or debit card to payPRQWKO\
billingsaccording to my regular billing schedule. I have read and agree to the AutoPay - Terms and Conditions
.
This authority is to remain in full force and effect until 1LJKWLQJDOH and card company has received
written notification from me (or either of us)
of its
termination in such time and in such manner as to afford 1LJKWLQJDOH at least fifteen-days prior to my (our) next payment. In case
of an erroneous debit, provided I (we) supply notice to my card company within 60 days of receiving my (our) account statement, the card company must
investigate and resolve the error within 45 days, but if it has not done so within 10 days, my (our) account will be credited for the amount in question while it
finishes the investigation.
Print Form
1iJKWLQJDOH6WDIILQJ,QF
AutoPay - Terms and Conditions-Credit Card
The AutoPay program is a service of1LJKWLQJDOH6WDIILQJ,QF provided as a convenience to our customers.
Customers requesting participation in the AutoPay Program with the 1LJKWLQJDOH agree to the following terms
and conditions upon signing the AutoPay Authorization Form
:
¾ To apply:
o Customers must provide a completed and signed AutoPay Authorization Form
o Completed forms are to be mailed to the address indicated on the form.
¾ To qualify for AutoPay, accounts must be in good credit standing with 1LJKWLQJDOH
Services and must remain current, and have a $0.00 balance at time of application.
¾ After AutoPay is approved, a full billing cycle may be required before AutoPay begins to draft from the
customer’s credit or debit card account. If the utility account is billed bi-monthly, this could be as much as
two months.
¾ Cards may not be used for billing in excess of $2,000. For accounts with larger balances, owing in
excess of $2,000 per billing cycle, please contact a customer representative to set up recurring depository
drafts (e.g. checking account), which has no amount limit.
¾ Funds will be withdrawn from the customer's card account on or after the bill's due date. The amount
withdrawn will be the amount due, as shown on the bill. Please indicate the Maximum Draft Amount
per bill on the application. If this is not filled in, 1LJKWLQJDOH6WDIILQJ,QF w
ill determine an
appropriate amount based upon your past six m
onths billing history.
¾ The regular bill serves as advanced notice of the amount to be drafted. Customer
s are responsible for
reviewing each bill for accuracy. Any disputes or changes must be communicated to 1LJKWLQJDOHV'LUHFWRURI
%LOOLQJprior to the bill's due date.
¾ Should funds not be made available by the card company, AutoPay participation may be terminated. In
such a case, the customer may also be subject to penalty charges, including but not limited to, any late
payment fees and a $40.00 fee for non-sufficient funds.
¾ Any disputed amount or other di
screpancy resolved after the card account has been drafted may be
adjusted within the 1LJKWLQJDOHVFXVWRPHU account and reflected on the customer’s next regular bill.
¾ Changes in a card’s expiration date may be adjusted by contacting a 1LJKWLQJDOH%LOOLQJ representative.
Changes in card account numbers will require a new AutoPay form. Please allow at least fifteen (15)
business days for changes to take effect.
¾ Customers may, without penalty choose to terminate this agreement at any time upon written notice to
the 1LJKWLQJDOH6WDIILQJ,QF'LUHFWRURI%LOOLQJ. Removal may require up to fifteen (15) business days to pr
ocess.
Any payments already in the drafting process at the time of notice may not be terminated.
¾ 1LJKWLQJDOH6WDIILQJ,QF reserves the right to change the program or
terminate participation at any time.
Notice of changes affecting the drafting processes, terms and conditions will be communicated.
Last Revised: 0D\
1LJKWLQJDOH6WDIILQJ,QF
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6DYDQQDK*HRUJLD
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AutoPay Authorization Form CreditDebit Card

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Completed 2 June 2021

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