ACH Authorization Form | Big Horn Rural Electric Company

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Agreement for Pre-Authorized Payment

I/we hereby authorize and request Big Horn Rural Electric Company, hereinafter called COMPANY, to effect payment for amounts due to COMPANY as such amounts become due by initiation debit entries to my/out account indicated below in the bank named below, hereinafter called BANK. I/we further authorize bank to accept any debit entries initiated by COMPANY to such accounts and to debit the same to such account without responsibility for correctness thereof.

I/we authorize that by signing this form I/we give COMPANY permission to reach out to BANK for any information that COMPANY might need verified.

It is understood that this agreement may be terminated by me/us at any time by written notification to COMPANY. Any such notification to COMPANY shall be effective only with respect to entries initiated by COMPANT after receipt of such notification and a reasonable opportunity to act on it.

Bank Name

Bank Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Bank Routing Number

Bank Account Number

Type of Account

Checking

Savings

Upload Voided Check for Checking Account or Voided Deposit Slip for Savings Account

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100 MB limit.
Allowed types: jpg jpeg png tif pict psd txt rtf html odf pdf doc docx.

Member Contact Information

First Name

Last Name

Phone Number

Email Address

This authorization agreement is given for the following accounts:

Signature

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Agreement for Pre-Authorized Payment