AUTOMATIC PAYMENT

AUTOMATIC PAYMENT WITH MCGD

THIS FORM DOES NOT AUTHORIZE ANY TRANSACTIONS WITH NEXTBILLPAY VIA CHECKING, SAVINGS, DEBIT/CREDIT CARD INFORMATION.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Customer ID*
Last 4 Digits Social Security # on Account*
Authorization*
I (we) hereby authorize Marshall County Gas District, hereinafter called DISTRICT, to debit entries to my (our) checking/savings account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same account.

I (we) understand that this authority is to remain in full effect unless:
• I discontinue gas service with the DISTRICT.
• The DISTRICT has received written notification from me (us) to stop the automatic draft from my (our) account, 7 business days prior to the draft due date.
• The DISTRICT has drafted my (our) account and no funds were available.

I agree to the Automatic Payment policy.
Agreed upon by:*
Date*
MM slash DD slash YYYY
Account Type*
- Checking Account
- Savings Account
Attach Image of Voided Check*
Max. file size: 128 MB.

Acceptable banking information: voided check from checking or savings or account information provided on bank letterhead. *Must specify checking or savings to participate. No Deposit Slips.
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