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| Form fields marked with an asterisk ( *) are required. |
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| Personal Information |
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First Name: |
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Middle Initial: |
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Last Name: |
Suffix: |
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Home Phone: |
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Work Phone: |
Ext: |
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| Service Address |
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Address: |
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City: |
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State: |
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Zip Code: |
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| Billing Address |
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Billing Address same as Service Address? |
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Address: |
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City: |
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State: |
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Zip Code: |
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| Biller Account Information |
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12-digit Consumers Energy Account Number: |
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| Financial Account Information |
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Financial Institution Name: |
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Routing Number: |
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Financial Account Number: |
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Financial Account Type: |
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Enter the last four digits of the primary account holder's Social Security Number: |
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Re-enter the last four digits of the primary account holder's Social Security Number: |
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| I authorize Consumers Energy to deduct my payment(s), including current and/or outstanding balances, from the checking or savings account listed above. I understand that in the event that I have any outstanding balance, that balance could be debited from said account within 24 hours of receipt of this authorization. I also understand that any current charges due will be withdrawn on my upcoming due date. I understand that I control my payments and to revoke this authorization, I will notify Consumers Energy in writing. |
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