ABC
PAYMENT PLAN - ENROLLMENT FORM
Print and complete the
form. Send the form with record of the bank account number you wish to use
for the bill payment transaction. Include a VOID personal check or a savings deposit slip
which includes your bank account number and bank routing number.
UGI Utilities, Inc.
Attn: ABC Department
P.O. Box 13009
Reading, PA 19612-3009
| UGI Customer Account Number |
| |
|
|
--- |
|
|
|
--- |
|
|
|
|
--- |
|
|
|
| Home Phone Number (with
Area Code) |
| |
|
|
-- |
|
|
|
-- |
|
|
|
|
|
| Work Phone Number (with
Area Code) |
| |
|
|
-- |
|
|
|
-- |
|
|
|
|
|
_________________________________________________________________________________________
Print Customer or Business Name (as it appears on your bill)
_________________________________________________________________________________________
(Business Customers please provide owner or manager's name above.)
_________________________________________________________________________________________
Service Address (where utility service is used)
City
State ZIP
_________________________________________________________________________________________
Name of Your Bank
_________________________________________________________________________________________
Name on Your Checking or Savings Account
Type of Account (Checking or Savings)
Checking Account
Information:
- Enclose a blank check
- Mark it "VOID"
Savings Account
Information: Ask your bank for these numbers.
_________________________________________________________________________________________
Bank Customer Account Number
Bank Transit Routing Number
Authorization Agreement
for Preauthorized Payments
By signing this, I authorize the financial institution (bank)
named above to charge my savings/checking account to pay my monthly UGI utility bills. I
agree that each charge to my account shall be the amount shown on my bill. I have the
right to stop payment of a charge by calling UGI within 5 days of receiving my bill. If I
stop payment 2 times in one year, UGI will take me off this plan. Also, I understand that
both my bank and UGI reserve the right to end this payment plan and/or my enrollment in
the plan. At any time, I may choose to be taken off this plan. If I so choose, I will give
notice upon receipt of my bill to UGI Utilities, Inc.
Signature_________________________________________________Date________________
|