AUTHORIZATION OF AUTOMATIC PAYMENT

I authorize Alliance and the bank named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it, and the telephone company has confirmed to me that it has been terminated. I am aware that any credit due my account must be approved by the appropriate telephone company personnel and will appear as a credit on the next monthly billing after the credit has been approved. Alliance reserves the right to cancel my use of the Automatic Payment Plan.

Mail this form to:
Alliance Communications
PO Box 349
Garretson, SD 57030.

Name of Financial Institution

Street

City State ZIP

Signature (if account is in two names, both must sign) Date

Name - Please Print

Address - Please Print

Telephone

Monthly Withdrawal Date

10th      15th      20th      No Preference

Checking Account No. Attach voided check below.

OR

Savings Account No. Attach savings account deposit slip below (only if using savings account).

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