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            Southeastern Indiana REMC               
  Secure Pay Form      

Please complete this form and send to:
Southeastern Indiana REMC
712 S Buckeye St.
Osgood, IN 47037

Customer Information

 		 Your Personal Banking Information
Customer Name ( as it appears on bill )

______________________________________
Service Address

______________________________________
City                        State                       Zip

_________________________________
Telephone		 Financial Institution Name

________________________________________
 Checking Account Number:

_________________________________________
Routing Number

 _________________________________________

_______________________________________
 Southeastern Indiana REMC Account Number		 *Please be sure to enclose a voided check for the checking account you wish to have debited

_______________________________
Signature                                            Date

Authorization form
                                           

_______________________________________
 I authorize Southeastern Indiana REMC to
 instruct my bank, savings and loan, or
credit union to pay my total bill from my
checking account listed.  I understand that
I control my payments, and if at any time I
decide to discontinue this payment service,
I will notify Southeastern Indiana REMC
in such time and manner so as to afford the
company reasonable opportunity to act on it. 
Discontinuance of this payment service shall
not affect any amounts owed by me to the
company.