311B AUTOPAY AUTHORIZATION

By signing below, I authorize Todd-Wadena Electric Cooperative and the financial institution named below to initiate entries to checking, savings, or credit/debit card account. This authority will remain in effect until I notify the Cooperative of cancellation.

MEMBER INFORMATION:

Account Number *

First Name *

Middle Initial

Last Name *

Phone Number *

Type of Phone *

Address *

City *

State *

Zip *

AUTOPAY AUTHORIZATION

By signing below, I authorize Todd-Wadena Electric Cooperative and the financial institution named
below to initiate entries to checking, savings, or credit/debit card account. This authority will remain in
effect until I notify the Cooperative of cancellation.

Choose one of the following: *

Checking

Savings

Credit/Debit Card

Financial Institution *

Routing Number *

Account Number *

Please Select Card Type *

Debit/Credit Card Number *

Expiration Date *

CVV Code *

I understand my account will be charged automatically on the bill’s due date. Payments declined or rejected for any reason will be subject to additional charges. This authorization remains in effect until above named Member notifies the Cooperative to cancel participation or until disqualified by the Cooperative. I will contact the Cooperative to update changes to my account such as new expiration dates or accounts numbers. This form will be destroyed within 45 days of receipt.

Member Signature *

clear

Today's Date * +

Todd-Wadena Electric Cooperative does offer paperless billings and automated electronic
notifications. A new member packet will be sent out with your account number. Once
received, if you would like to elect any of these features, please go to our website
www.toddwadena.coop, sign up for SmartHub and elect any of these options.

This institution is an equal opportunity provider and employer.