ELECTRONIC DEBIT PROGRAM AUTHORIZATION
 NEW APPLICATION    CHANGE IN APPLICATION.
Customer name (as it appears on KEYS' account):
KEYS' Service Address:
Telephone Numbers:     Work     Home:     Cell
E-mail Address:        E-Bill/Paperless Bill: Yes     No
Keys Energy Services Account(s) to be credited:
Deposit Waiver       The payment of security deposit will be required immediately upon removal from the program.
CHECKING/SAVINGS ELECTRONIC DEBIT (No Fee)    If selected, please input financial information below:
Financial Institution Information
Bank Name:
Your Name:
Routing Number:
Account Number:
Account Type: Checking    Savings.
Account Designation: Consumer (Personal)    Business
CREDIT/DEBIT CARD ELECTRONIC DEBIT (Transaction Fee Assessed)   If selected, please input credit/debit card information below:
Credit/Debit Card Information
Credit/Debit Card Number:          Expiration Date (MM/YY):
Name On Card:
Credit/Debit Card Type: Visa    MasterCard    American Express    Discover         Credit/Debit Card Security Code:

Authorization Agreement for Electronic Debit Program

I hereby authorize the Utility Board of the City of Key West, "Keys Energy Services," hereinafter called KEYS, to initiate electronic debit entries and to initiate, if necessary, electronic credit entries and adjustments for any electronic debit entries in error to my account indicated above, and the financial institution or credit/debit card named above to electronically debit and/or electronically credit the same to such account. I agree to allow KEYS to electronically debit my account for my electric billing approximately 2 business days prior to the due date. If a monthly billing is not received it is the customer of record's responsibility to contact KEYS to obtain the billing amount.
I further agree that if any such electronic transaction be returned or denied, whether with or without cause, KEYS shall be under no liability whatsoever, even though such return or denial results in the disconnection of electric service.
This authority is to remain in effect until revoked by me, and until KEYS actually receives such notice, I agree that you shall be fully protected in drawing any such electronic debit or electronic credit. KEYS reserves the right to cancel the electronic debit program 30 days after notification. I understand that if any such electronic debit does not clear, and any amount due KEYS is not paid in accordance with the terms of the Customer Service Policy Manual, electric service to my account may be subject to disconnection. Should any electronic debit be returned or denied, I understand that my account will be removed from the electronic debit program. Any item returned to KEYS as uncollectible or denied will be subject to a $25.00 fee or 5% of the billing, whichever is greater. I understand that my request for electronic debit will take effect immediately and I receive a bill stating "Do Not Pay." Should any change in financial institution or credit/debit card occur, I will notify KEYS within 30 days of the change. Should I wish to discontinue participation in the Electronic Debit Program, I will notify KEYS 30 days prior to the actual termination date of the program.
If enrolled in the electronic debit program via credit/debit card, I agree to provide KEYS with a new authorization form prior to the expiration date as noted above if I am to continue to participate in the Electronic Debit Program. I also agree to the monthly transaction fee assessed when payment is processed.

I understand that by checking the box next to the words "I ACCEPT" and typing my name below, I am signing this document electronically.
I ACCEPT
KEYS' Account Holder Signature:   Date:
I ACCEPT
Account Holder Authorization Signature:   Date:
(IF DIFFERENT FROM KEYS' ACCOUNT HOLDER)
KEYS Representative:   Date:
Form last revised: 04/10/15