Automatic Payment Plan
Authorization Agreement for Pre-Authorized Payments

With the Automatic Payment Plan, your bank or financial institution makes your payments directly to Bernard Telephone Company on the 20th of the month. It’s simple, just fill out the information needed and we take care of the rest.  You will continue to receive a monthly bill, but we will automatically handle your payment through your financial institution.
To sign up for this free service, please fill out the form and send it with your personal voided check or copy of a voided check. The account must be current. If it is a joint account, both signatures are required on this application.


I (we) hereby authorize Bernard Telephone Company to initiate debit entries to my (our) checking account indicated below and the depository (Bank) name below, hereinafter called DEPOSITORY (Bank), to debit the same to such account and if necessary, to make adjustments to the account for any entries made in error.

DEPOSITORY (Bank)
Name: ______________________ Branch:____________________ 
City: __________________State:_________    Zip:_______________

Transit/ABA Number:_______________________                    

Account Number: _________________________

Name(s) on account: __________________________________

Telephone number: __________________ 

Signature: _________________________________________

Date:_______________________

Signature:___________________________________________

Date:________________________
Return completed form with a voided check (or copy of your voided check) to:  

Bernard Telephone Company PO Box 68 Bernard, IA 52032