Enroll in Bank Draft Plan - Print & Mail

BANK DRAFT PLAN

*Required Fields

Name:	(As shown on Alagasco Account)
*First Name:
*Last Name:
Email:
*Alagasco Account #:
Please deduct my payment monthly from:
*Type of Account:
*Name on Bank Acct:
*Bank Routing #:
*Customer Bank Acct #:
*Bank Name:

	Yes, I want to participate in Alagasco’s Bank Draft Plan:
	AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS: I hereby authorize Alagasco to initiate debit entries to my Banking Account indicated above at the Bank named above to make payments on my Alagasco account, and to debit the payments to my Banking Account. I understand that the payments will be made each month on the payment due date in the total amount due, as shown on my Alagasco billing statement. I understand that this authorization will remain effective until I have notified Alagasco to cancel or change it, and Alagasco and the Bank have had a reasonable opportunity to act on it. I acknowledge that the origination of ACH payments to my Banking Account must comply with the provisions of U.S. law. Signature: _______________________________________