Authorization Form for Citizens'

Electric Easy Pay Plan

Please enter the information as it appears on your electric bill.

Account Number: _______________________

Name: _______________________

Address: _______________________

City: _______________________

State: _______________________

Zip Code: _______________________

Bank Information

Name on Account:________________________________________

Name of Financial Institution___________________________

Check one:

Checking Account (Provide void check)

Savings Account - Account #: _________________

Bank ABA Routing #:_________________

Authorization Agreement for Prearranged Payments

I hereby authorize my financial institution and Citizens' Electric (citizens) to charge the account specified in the amount of my monthly citizens electric bill and send that amount to citizens. I agree that each charge to my account shall be the same as if I had signed a check to pay my bill. This authority will remain in effect until I supply citizens with WRITTEN NOTICE to terminate the Easy Pay Plan. Notice must be 15 days before the due date and shall be effective only with respect to payments after the Company's receipt of such notification. In addition, I have the right to stop payment of a charge by notifying my financial institution before the stated due date. I understand that both the financial institution and citizens reserve the right to terminate this payment plan and/or my participation therein. If I discover a problem with my monthly electric bill, I will give citizens at least 4 working days notice prior to the due date to adjust the bill amount, if necessary. Otherwise, I will not expect any interest on over-payments due to errors. Failure to notify citizens of closing my bank account or to maintain sufficient funds will result in additional services charges.

Signature: (Required)___________________________

Date:____________