Please close this window once you are done printing.

Please print out this form, complete and return to: Jackson Electric Cooperative, P.O. Box 546, Black River Falls, WI 54615 Please Check Appropriate Box(es)
___	I would like to participate in the Budget Plan only. (Complete customer information only.)
___	I would like to participate in the Direct Payment Plan only. (Complete entire form plus requested enclosure.)
___	I would like to participate in both the Budget & Direct Payment Plans. (Complete entire form plus requested enclosure.)

Customer Information

Name (as shown on bill)	___________________________________
Jackson Electric Cooperative Account Number	___________________________________
Phone Number	___________________________________
Service Address (if different from mailing address)	___________________________________
Mailing Address	___________________________________
City	___________________________________
State	___________________________________
Zip	___________________________________
Signature	___________________________________
Date	___________________________________

Continue for Direct Payment Plan I authorize Jackson Electric Cooperative to instruct my financial institution to make my payments to them from the account listed below. I understand that I control my payments, and if at any time I decide to discontinue this payment service, I will notify Jackson Electric Cooperative in writing.

Financial Institution Name	___________________________________
Address	___________________________________
Phone Number	___________________________________
Type of Account	___ Checking ___ Savings
Account Number	___________________________________

Financial Institution Routing/Transit Number (as noted between the and symbols on the check bottom.) ________________________________________

Please enclose a voided check or withdrawal slip, so that we can record the correct financial institution information.

Please close this window once you are done printing.