I authorize Black Hills Electric Cooperative, Inc., and the financial institution named below to initiate entries to my checking/savings account or my Visa or MasterCard. This authority will remain in effect until I notify BHEC in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution three (3) days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account. (Note: A voided check or a deposit ticket must be included for checking/savings account authorization.)
BHEC's Financial Institution for Automatic Payment Plan is
First Western Bank
648 Mt. Rushmore Road, Custer, S.D. 57730
Please Print your name exactly as it appears on your account or credit card.
Name: ____________________________________________________
Address: __________________________________________________
Checking Account Number: ___________________________________
(OR)
Savings Account Number: ____________________________________
Financial Institution Routing Number: _____________________________
(Numbers between the |: |: symbols on the bottom of your checks.)
Credit Card: ___ Visa ___ MasterCard Card Number: ___________________ Expires: ______
Signature: _____________________________ Date : ______________
Please print this form, fill in the appropriate information, sign and mail it and a voided check or deposit ticket to: Black Hills Electric, Box 792, Custer, SD 57730-0792.
