Automatic Payment Plan

You will continue to receive a monthly bill. The deduction will occur on the 15th of the month. When the 15th falls on a day the business office is closed, the deduction will occur the following business day. The Automatic Payment Plan will continue in effect until TrioTel receives notification of termination; subject to the file processing date. Any payment returned for non-sufficient funds will be assessed a $30.00 surcharge, and may result in removal from the Automatic Payment Plan.

I authorize TrioTel to initiate entries to my checking/savings account.

Date*
MM slash DD slash YYYY
Name*
First Last
Home Phone or Account Number*
Contact Number*
Email Address*
Name of Bank*
Account Type*
- Checking
- Savings
Bank Routing Number (first set of numbers)*
Bank Account Number (second set of numbers)*
Signature*