Automatic Bill Payment Authorization

Member Name

Account # or Service Address

Phone #

Member Email

Banking Information

Name of Account Holder

Bank Routing #

Checking/Savings Account #

Voided Check

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Credit Card Information

Name On Card

Billing Address With Zip Code

Card #

Card Type

Visa

MasterCard

Discover

American Express

Expiration Date

Authorization Code

I agree to the terms of service.

Terms of Service

I (We) hereby authorize Heart of Texas Eletric Cooperative, Inc. to initiate debit entries to my (our) credit card or checking/savings account as indicated above, to the financial institution or credit card company named above and to debit the same to my account.
I further understand that the cooperative may impose a service charge in the event that a debit entry is not paid or is rejected by my financial institution or or credit card company.

Signature

Sign above

Date Signed

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