AUTOMATIC PAYMENT

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 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*
Date Format: MM slash DD slash YYYY
Attach Image of Voided Check*
No Deposit Slips
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