By signing and returning this completed form, you agree to sign up for the
Direct Payment Plan and have your monthly gas bills automatically deducted from
your bank account. Once your application is keypunched your Direct Payment withdrawal will begin in two billing
cycles. Please continue to pay your bill until your Direct Payment becomes active. Your bill will
reflect the withdrawal date.
Please complete this form, print, sign, and mail to:
Cash Management
Bay State Gas/ Northern Utilities
995 Belmont Street
Brockton, MA 02401-5586
Bay State Gas / Northern Utilities Account No. (see bill)
Name (as it appears on the bill):
Street Address:
City / Town:
State:
Zip Code:
(Include at least 5 digits)
Phone: Day:
Evening:
Bank / Financial Institution:
Bank Account Number:
ABA / Routing Number:
Account Type:
Checking
Savings
Date:
In signing below, you authorize Bay State Gas / Northern Utilities and the bank
/ financial institution indicated above to automatically deduct from your bank
account all future payments for your gas bills.
You can discontinue this service at any time by notifying the company.
Be sure to attach an original voided check (no deposit slips, please)
to this form before mailing to the company.
Signature ________________________________________
To print this form, click here.
