Name:_____________________________________________________________________

Address:__________________________________________________________________

City:_________________________________ State:_________________ Zip:_______

Daytime Phone Number:_____________________________________________________

WIN Energy REMC Account Number(s):________________________________________

I wish to enroll in WIN Energy REMC's Budget Billing Program. I understand that all bills must be paid on time in order to remain in this program. Further, when all accounts are balanced in June of each year, I understand that any credit remaining will be refunded and any amount still owing must be paid by the due date to insure my continued participation in Budget Billing.

Signature:____________________________________________

Date:_________________________________________________

This request does not guarantee enrollment in the program. If accepted, please allow 30 days for budget billing to be reflected on your bill. You will receive a written confirmation noting your budget amount for the coming year and the date your first payment will be due. Should you wish to be removed from this program, please notify WIN Energy REMC in writing. Any account not kept in good standing will be removed from budget billing after being notified in writing.