TIPMONT REMC

PO BOX 20

LINDEN IN  47955-0020

1-800-726-3953

Direct Pay Request Form

By completing the form below, I authorize Tipmont REMC to initiate variable entries to my account identified below for payment of my electric bills.  In making this authorization, I agree to all terms printed at the end of this form.

Customer Name

Address

City                                                                  State                                        Zip

Tipmont REMC Account #(s)

Home Phone #                                                   Work Phone #

Bank Account #

Authorized Signature                                          Date    

Please remember to attach a blank check marked “VOID”.  Thank you.

Authorization Agreement

I hereby authorize the financial institution named on the reverse side to pay my monthly Tipmont REMC electric service bill by charging each payment to my account.  I agree that each payment shall be the same as if it were an instrument personally signed by me.  This authority is in effect until revoked by me in writing.  In addition, I have the right to stop payment of a charge by timely notification to my financial institution prior to charging my account.  I understand, however, that both the financial institution and Tipmont REMC reserve the right to terminate this payment plan or my participation therein.