WIN ENERGY REMC AUTOMATIC PAYMENT PLAN AUTHORIZATION FORM
(Please Print or Type)

Name:_____________________________________________________________________

Address:__________________________________________________________________

City:_________________________________ State:_________________ Zip:_______

Daytime Phone Number:_____________________________________________________

WIN Energy REMC Account Number(s):________________________________________

Credit Cards Accepted:
VISA______ or MasterCard______

Card Number:_______________________________________
Expiration Date:_____________________________________
3-digit Verification Code:______________________________
(Printed on card back in signature panel)

I understand:

  • I will receive a monthly bill that will state "Do Not Pay-Credit Card is Being Charged for the Amount Owed."
  • It is my responsibility to inform WIN Energy of any change in my credit card number or expiration date.
  • If my credit card is declined for any reason a fee will be charged to my electric account and I will be removed from the program. I must complete another authorization form to enroll again.
    •  Bank Draft:
    Savings______ or Checking______

    Name of Bank:___________________________________________
    Bank Routing No.:_______________________________________
    Bank Account Number:_____________________________________
    Please attach a check marked VOID.

    I understand:

  • I will receive a monthly bill that will state "Do Not Pay-Account is Being Drafted for the Amount Owed."
  • It is my responsibility to inform WIN Energy of any change in my bank account and bank routing numbers.
  • If my bank draft is returned for any reason a fee will be charged to my electric account. If two bank drafts are returned I will be permanently removed from the program.

    • I authorize automatic payment of my monthly electric bill(s) on the due date. I understand it may take one to two billing cycles for the plan to be implemented. WIN Energy REMC reserves the right to limit participation to customers whose accounts are in good standing. I may discontinue my participation in the program by notifying WIN Energy REMC in writing.

    Authorized Signature:____________________________________________ Date:_________________

    Please return form to WIN Energy REMC, 3981 S US Highway 41, Vincennes, IN 47591

    For Office Use Only:
    Bank Number_____________
    Billing Cycle_____________
    Effective Date_____________