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An Independent Telephone Company Since 1909

AUTHORIZATION AGREEMENT FOR ELECTRONIC PAYMENTS

Complete this form including the bank account you want charged. Print, sign and return to our Business Office. We will debit your account each month for the amount due on your phone bill until you notify us to discontinue doing so. You will continue to receive a statement from State Telephone each month with all of the regular bill information. After your account is debited, our name will appear [on your bank statement] so you can easily see the amount that was paid.

I (we) authorize State Telephone Company to initiate debit entries to my (our) Checking Account indicated below on a monthly basis for only the amount due on my (our) State Telephone Company bill for that month.

Bank Name: _________________________________________________________

Routing/Transit (ABA) Number: _______________________________________

Account Number: ____________________________________________________

This authority is to remain in full force and effect until I (we) notify State Telephone Company of its termination in such time and in such manner as to afford State Telephone Company a reasonable opportunity to act on it.

Name(s)	Telephone Number(s)
____________________________ (Please Print)	____________________________
____________________________ (Please Print)	____________________________
Date: ______________________	Signed: ____________________________
Date: ______________________	Signed: ____________________________
Please return this form to the business office:	State Telephone Company Attn: Electronic Payment 46 Reed Street Coxsackie, NY 12051