SouthEastern Illinois Electric Cooperative, Inc.

AUTOMATIC DRAFT SERVICE AUTHORIZATION FORM

       Date:  ______________________

       SEIEC Account #(s):  ____________  ____________  ____________  ___________
       
       Name:  ______________________________________________________________

       Address:  ____________________________________________________________

       City, State, Zip:  _______________________________________________________

       Phone #:  ________________________________


  Bank Draft:

       Financial Institution:  __________________________________________________

       Routing #:  _______________________  Account #:  ________________________

       ____Savings            ____Checking (Include a Voided Check)



  Credit Card Draft:

       Account #:  _____________________________________________

       Expiration Date:  ________________________________________

       ____Visa        ____MasterCard             ____Discover

 
I hereby authorize SouthEastern Illinois Electric Cooperative, Inc. to debit my account in payment of electric service at the account listed above.  This authorization may be terminated up to four working days before the bank draft payment date, upon the request of either party.  I understand that my account will be drafted monthly until I notify SouthEastern Illinois Electric in writing that I wish to terminate using the Automatic Draft Service.

               Print, complete, and mail this form to: 
               SouthEastern Illinois Electric Cooperative, Inc.
               PO Box 251
               Eldorado, IL  62930