Fillable Printable Automatic Bank Draft Authorization Form - CoServ

Automatic Bank Draft Authorization Form - CoServ

COS 5089 REV 12-2011

AUTOMATIC BANK DRAFT AUTHORIZATION FORM

All information is required before processing.

PERSONAL INFORMATION

FINANCIAL INFORMATION

Name (Please Print)

Name of Financial Institution

Service Address

Financial Institution Address

City,State and ZipFinancial Institution City, State and Zip

Telephone Number

Financial Institution Telephone Number

E-mail Address

Routing Number

(First 9 Digits at bottom of check)

Checking Account Number

Please contact your financial institution to confirm the appropriate ACH bank routing number and correct bank account number.

These numbers may differ from your checking account number.

Upon receipt of this completed authorization form, bank drafting of payments for the account(s) listed below will begin on the next

billing statement. The word “Bank Draft” will appear on your billing statement and the date of the draft will be indicated on the

statement. The payee on the statement from your bank will indicate Denton County Electric Cooperative, Inc., d/b/a CoServ Electric.

I grant authority to CoServ Electric and/or CoServ Gas to draft my account listed above for payment amounts

due on theaccount(s) listed below. The financial institution listed above is authorized to pay such drafts when

so drawn and presented forpayment until authority is revoked.

_____________________________________________________________________________

Signature (as accepted by your Financial Institution)Date

Please list below the CoServ Electric and/or CoServ Gas account number(s) for each account you would like to

be paid by bankdraft:

CoServ Account Number(s)

______________________________________

Forward Completed Authorization Form

E-mail: contact@coserv.com

Fax to: (940) 270-6640—ATTN: Customer Service

Or Mail to:CoServ (ATTN: Customer Service)

7701 S Stemmons, Corinth, TX 76210

If you have questions, please contact Customer Service at (940)321-7800 or (800) 274-4014

during the hours of8 a.m. to 5 p.m., Monday through Friday.