Automatic Payment Plan Form

Fulton County REMC Authorization Form for the Automated Clearning House (ACH) Bill Payment Service

Please print and fill out the following form to authorize your account for our Automatic Payment Plan. Once the form is completed, please see additional instructions below.

Name:_____________________
(As it appears on your bill)

Address:__________________

City:_____________________

State:______Zip___________

Phone:____________________

REMC Account Number (or numbers):

Account 1________________

Account 2________________

Account 3________________

Account 4________________

Name of Bank:_________________

Bank Acct. #:_________________

Account Type:

 checking
 savings

I authorize Fulton County REMC to draw monthly bank drafts on my bank account shown above for the payment of my monthly electric bill. I understand that I can discontinue my participation in ACH by notifying the REMC in writing. Both the REMC and the bank also may terminate this agreement with 10 days written notice. I understand that the REMC reserves the right to limit participation in ACH to members whose accounts are in good standing.

Signature___________________

Date________________________

Please attach a check marked "VOID." Your bill will indicate that your payment is being made automatically by displaying the message "BANK DRAFT-DO NOT PAY." The date the account will be drafted will also appear on the bill. Please allow one to two billing periods for the plan to be implemented.