Yes, I want to participate in the Automatic Payment Plan.

I authorize Pierce Pepin Cooperative Services/SwiftCurrent Connect to instruct my financial institution to make payment to them from the account listed below on or about the due date indicated on my electric and/or internet/voice bill(s), or as soon thereafter as possible. I understand that I control my payments, and if I decide to discontinue this service at any time, I will notify Pierce Pepin Cooperative Services/SwiftCurrent Connect at least 15 days before the due date indicated on my bill(s) for the current month by phone, in writing, or by email. I also understand that Pierce Pepin Cooperative Services/SwiftCurrent Connect has the right to terminate my participation in the Automatic Payment Plan at any time and will notify me of such termination in writing or by email.

If your payment is returned unpaid, a fee of $30.00 will be added to your charges at that time. (This fee represents the charge placed on Pierce Pepin Cooperative Services by its financial institution when a returned payment is processed.)

I (we) acknowledge that the origination of the ACH transactions from my (our) account must comply with the provisions of the United States law, and for non-consumers, I (we) agree to be bound by the provisions of the Nacha Operating Rules.

Member/Customer Information

Address
Apply Automatic Payment to These Accounts:

Electric Account(s):

Internet/Voice Account:

Financial Institution Information

Address
Type of Account:
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NOTE:  Allow up to 15 days from the date PPCS/SwiftCurrent Connect receives this form for automatic payment to be available. It is your responsibility to ensure that any amounts due, including past due amounts, during that 15-day period are paid.