Autopay Program Form

Name*

First Last

Southern Indiana Power Member Account Number*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Alternate Phone

Email

Bank Draft*

Check Image (front only)*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 30 MB.

Routing Number*

Account Number*

Bank Name*

Consent*

I agree to the privacy policy.

I, authorize Southern Indiana Power to draw monthly bank drafts on my bank account shown above for the payment of my monthly electric bill. I understand that I may discontinue my participation in Autopay by notifying the cooperative in writing. Both Southern Indiana Power and the bank may terminate this agreement with ten (10) days written notice. I understand that the cooperative reserves the right to limit participation in Autopay to customers whose accounts are in good standing.

Applicant Electronic Signature (Full Name)*

Date*

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Savings