Name(s) on the Account: _______________________________________________________________________________
Mailing Address: ____________________________________________________________________________________
City: _____________________________________________________________________ State: ______ Zip: __________
Golden West Account # (s): ____________________________________________________________________________
Financial Institution: __________________________________________________________________________________
Financial Institution Address: __________________________________________________________________________
Type of Account: o Savings Account o Checking Account
Please attach a voided check.
Bank Routing #: _________________________________ Bank Account #: __________________________________
Date to Deduct:
o 5th o 10th o 15th o 20th
Select a payment date that falls on or before your statement due date.
You authorize regularly scheduled payments to be deducted from your checking or savings account.
You will continue receiving your monthly statement from Golden West Telecommunications. The bill
you receive will have a printed message stating: DO NOT PAY THIS BILL – AMOUNT DUE WILL BE
The bill you receive will provide you with the amount that will be deducted from your bank account. The
monthly automatic deduction from your bank account will occur no earlier than the date you select below.
Authorization Agreement for Golden West Telecommunications Bank Deduct
This authorizes Golden West Telecommunications and the financial institution named below to initiate
entries to the listed checking or savings account.
Signature of
Golden West Account Holder:
________________________________________________________ Date: _____________
Signature of
Bank Account Holder:
________________________________________________________________ Date: _____________
This authorization remains in effect until Golden West is notified to terminate it.
Golden West reserves the right to terminate this payment plan at any time.
You may also register for a paperless e-Statement at:
O Box 411 • 415 Crown Street • Wall, SD 57790
1-855-888-7777 • Fax: 605-279-2747 •