Save time and money by signing up for LISCO's automated payment system. For your convenience, and with the help of your bank, we can automatically deduct the monthly fees you owe to LISCO from your checking account. No more checks to write! No more bills to open. No more stamps to lick. Simply print out this page, fill out and sign the top part of this form, attach a voided check, then mail this form and the voided check to LISCO at the address listed below. I/We acknowledge that the origination of ACH transactions to my/our account must comply with the provisions of U.S. law.
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| Your LISCO username: | |||
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| Home phone: | Work phone: | ||
I authorize LISCO (Local Internet Service Company, Inc.) to automatically withdraw my monthly service charge from the checking account indicated on the attached voided check. This authorization is to remain in full force and effect until LISCO has received written notification from me of its termination in such a manner to afford LISCO a reasonable opportunity to act on it. I also understand that if my LISCO Internet account is a metered account, any extra charge for usage over the allowed limit will also be withdrawn from my checking account. The first automatic withdrawal from my checking account will take place on the next billing cycle after receipt of this signed authorization by LISCO.
Signature:_______________________________________
Date:_________________
For Office Use Only (by LISCO)
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Customer ID
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Routing #:
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Bank account #:
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INSTRUCTIONS | |
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1.
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Print out this form. | |
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2.
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Fill out the top part of this form, including the signature and date lines. | |
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3.
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Write "void" on one of your checks, then attach the voided check to this form. | |
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4. |
Mail
this form (and your voided check) to: LISCO P.O. Box 1750 Fairfield, IA 52556 |
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