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 Zip Financial 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 the account(s) listed below. The financial institution listed above is authorized to pay such drafts when
so drawn and presented for payment 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 bank draft:
CoServ Account Number(s)
______________________________________
______________________________________
______________________________________
______________________________________
Forward Completed Authorization Form
E-mail: contact@coserv.com
Fax to: (940) 270-6640ATTN: 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 of 8 a.m. to 5 p.m., Monday through Friday.
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