Authorization Agreement for Automatic Bill Payment

Contact Info

Consumers Energy Cooperative
2074 242nd Street
Marshalltown IA, 50158

Phone: 800-696-6552

Authorization Agreement for Automatic Bill Payment

FOR MEMBERS OF CONSUMERS ENERGY COOPERATIVE OF IOWA ONLY!!

With the Automatic Bill Payment Plan, payments are automatically posted to the member’s checking account or debit / credit card. This is a free service. When on this plan, a monthly electric bill will be mailed to the member that states “Bank Draft - Do Not Pay” or “Credit Card - Do Not Pay.” When the payment date falls on a weekend or holiday, the withdrawal will be processed on the following business day. {Form #75, 02/13/2015, kjg}

Consumers Energy Account Number

Address

City/Town

State/Province

ZIP/Postal Code

Name(s) on Consumers Energy Account

Phone Number

Select only one of the following automatic bill payment options:

Checking Account OR Debit/Credit Card.

The necessary information, documentation and signatures must be provided.

Checking Account

Checking Account Information

*A voided or photocopy of the member’s check must be provided.

*It may take up to 30 days for bank features to be effective for automatic bill payment.

Depository Bank Name

Bank City/State

Routing Number

Checking Account Number

Draft Date -select one

Copy of voided check

One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Debit/Credit Card Option

Debit/Credit Card Information

The electric bill payment will be posted on the 3rd of each month.

Indicate Card Type

Credit Card Number

Expiration Date

Name on Card

CID Code

Last 3-digit or 4-digit number on back side of debit / credit card

Authorization Agreement

This Authorization Agreement will be in effect with submission of this completed form with the required signature(s), which authorizes Consumers Energy to initiate debit entries to the checking account or debit / credit card referenced. If the member account is a joint account, this Authorization Agreement must have both signatures. The designated depository bank / card issuer is authorized to debit the payment amount to the cooperative’s member account. This agreement will be in force until cancelled by the member or Consumers Energy. By providing your full legal name in signature field here, you acknowledge that the form is accurate and binding (pending accurate completion of all other form sections). It is not necessary to print and sign the form if users plan on submitting the form electronically. I agree that my electronic signature on this agreement/document has the same effect as a signature signed in ink.

Signature

Sign above

Signature Disclosure Statement

For the purpose of Consumers Energy online forms, when the word "signature" or "signature of responsible party" appears, a typed, legal name is an acceptable substitute. As long as the complete, legal name appears in each blank for which a signature was requested, the form is accurate and binding (pending accurate completion of all other form sections). It is not necessary to print and sign the form if users plan on submitting the form electronically. I agree that my electronic signature on this agreement/document has the same effect as a signature signed in ink.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.