ACH Form

Day of the Month for the Withdrawl*

If you do not have a preferred day, your payment will be deducted on the 10th. All bills are due the 20th of the month

I wish to use Bank Collect (ACH)*

YesNo

I wish to receive Paperless Statements*

YesNo

I hereby authorize Marne Elk Horn to debit my checking or savings account each month for the amount of my monthly bill. I agree that Marne Elk Horn’s rights inrespect to each payment shall be the same as if it were a payment personally authorized by me. This authority is in full force and effect until Marne Elk Horn hasreceived written notification from me of its termination in such time and manner as to afford Marne Elk Horn and our financial institution a reasonable opportunity toact on it.

METC Account Number *

Name on Account*

Email*

Bank Name*

City, State, Zip*

Account Number*

Transit/ABA Number*

Signature*

For verification purposes, a voided check must accompany this agreement.

Verify*