Fillable e -Check Authorization Form Please print this form,

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e -Check Authorization Form Please print this form,

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The e -Check Authorization Form Please print this form, form is 1 page long and contains:

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e
-Check Authorization Form
Please print this form, complete and sign it, attach requested documentation, and mail or deliver to
NOVEC as indicated at the bottom of this form.
Name (as shown on NOVEC bill): ___________________________________
Address: _________________________________________________________
Daytime phone number: __________________________
NOVEC account number: ___________________
NOTE: If you have more than one account, list all account numbers to be included in the e-Check payment plan.
Bank Information
Name of bank: ___________________
Name of bank account holder: ____________________
Bank account number: _________________
I authorize the financial institution named to charge my:
C
hecking account (enclose voided check)
Savings account (enclose voided deposit slip) and
remit payment for my monthly electric bill to NOVEC.
I understand that I control my payment and if at any time I decide to discontinue the e-Check payment plan, I
will notify Northern Virginia Electric Cooperative in writing.
Signature of authorized bank account holder:
__________________________ Date: _____________________
If you have any questions, please call one of our customer service representatives at 703-335-0500 or toll-free
at 1-888-335-0500. You can also email customer service at
customerservice@novec.com.
Return the completed form along with a voided check or deposit slip by one of the following methods:
Fax:
703-392-1740
Mail:
NOVEC e-Check Program
P.O. Box 2710
Manassas, VA 20108-0875
In Person:
Manassas
10323 Lomond Drive
Manassas, VA 20108-3173
Lobby Hours: 8:15 a.m.-5 p.m.
Payment drop box available
Gainesville
5399 Wellington Branch Drive
Gainesville, Virginia 20155-1616
Payment drop box available
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e -Check Authorization Form Please print this form,

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Completed 30 May 2022

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