Fillable Automatic Payment Option

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Automatic Payment Option

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The Automatic Payment Option form is 1 page long and contains:

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  • 10 check-boxes
  • 14 other fields

Country of origin: OTHERS
File type: PDF

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Customer name:
Reliant account number:
Breathe easy knowing your account is paid on time every
month with AutoPay. Signing up is quick and convenient.
Visit reliant.com/autopay to get started. You can also sign
up by mailing this form to: Reliant, P.O. Box 228, Houston,
TX 77251-0228 or by faxing it to 1-866-781-0407.
Automatic Payment Option
Select only one below.
All account information will remain condential.
Automatic Bank Draft Type of bank account: Checking Savings
Name as it appears on bank account:
Complete the information and attach a voided check before returning this form. Please allow up to 30 days to process.
In the interim, you should continue to pay all invoices until you receive one marked “Do Not Pay.” Once your automatic
payment option is established, you will continue to receive monthly invoices marked “Do Not Pay” for your records.
Name of banking institution:
Bottom of standard check or deposit slip.
Routing # (9 digits) Account # Check #
:123456789|: 987654321||. 0101
Routing number:
Bank account number:
I have read and understand the terms found on the back of this form.
Signature: Date:
Daytime phone number: Evening phone number:
Automatic Credit Card Payment Visa MasterCard Discover Network American Express
Name on card:
Card number: Exp. date:
Cardholder billing address:
I have read and understand the terms found on the back of this form. I authorize Reliant to charge my monthly Reliant
invoice to my credit card for the amount of my monthly Reliant invoice.
Signature: Date:
Thank you! Return this completed form to Reliant, P.O. Box 228, Houston, TX 77251-0228
or fax it to 1-866-781-0407. If you have a question, visit reliant.com/autopay or call 1-866-RELIANT.
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Automatic Payment Options – Terms and Conditions
To be eligible for an automatic payment option, your account must be in good standing and you may not
have two or more returned payments during the past twelve-month period. If your account is eligible, you
will be enrolled in the automatic payment plan of your choice. In the interim, please continue making regular
payments until you see “Do Not Pay” on your invoice or in your Reliant online account. Reliant may terminate
your participation in automatic payment options in the event you provide incorrect, false or fraudulent
account information. After your rst returned payment item, your automatic payment plan will be temporarily
deactivated and may only be reactivated upon verication of your payment account information. Once you
have more than one returned payment, your account may be ineligible for reactivation on automatic
payment options for up to six months. Your bank account and credit card account information will be used
only for the purposes of setting up your account for automatic monthly payments, and Reliant will keep your
account information condential. For more information on the Reliant Privacy Policy, please log on to reliant.
com. Direct inquiries to Reliant, P.O. Box 228, Houston, TX 77251-00228 or call 1-866-RELIANT.
*
Visa is a trademark of Visa, Inc. Discover Network and the Discover Network Acceptance Mark are trademarks of Discover Financial
Services. MasterCard is a registered trademark of MasterCard International Incorporated. American Express is a registered trademark
of American Express. Reliant is not aliated with Visa, Discover Network, MasterCard, American Express or any of the programs or
promotions of these entities.
Automatic Payment Authorization
By providing my bank account or credit card account information to Reliant and signing in the space provided,
I hereby authorize Reliant to charge my account in the amount of my monthly invoice. For bank drafts,
I authorize Reliant to keep my signature on le as a record of my authorization to charge my bank account.
I understand that debits to my checking account will be withdrawn or charged on the due date reected
on my invoice, unless such date is a Saturday, Sunday or other bank holiday, in which case Reliant will debit
my account on the next banking day. I understand that my Reliant monthly invoice together with this
authorization form will be notice of the amount and the date of each withdrawal from my bank account or
charge to my credit card. I understand that any past due balance on my account will be charged as soon as
my enrollment is processed. I also understand that I may cancel my automatic payment option at any time
online at reliant.com/myaccount or by calling 1-866-222-7100. I also agree to notify Reliant if there are any
changes to my bank or credit card account information.
Reliant Retail Services, LLC (PUCT Certicate #10007) © 2018 Reliant Retail Holdings, LLC . All right s reserved.
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Automatic Payment Option

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Completed 27 September 2021

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