I authorize NIPSCO and the financial institution listed below to transfer (debit) money from the indicated checking account for payment of my NIPSCO bill. I will continue to pay my bill by check until I am notified that my ZapCheck service has started.

Customer Name (as on bill)

Your NIPSCO Billing Account Number

Service Address (Street/City/State/ZIP Code)

Mailing Address (if different)

Daytime Phone Number (with area code)

Financial Institution Name

Is this a Credit Union?

YES   NO

Address (Street/City/State/ZIP Code)

Account Number - Savings or Checking (circle one)

Authorized Signature

Date

Please choose (and check) one of the following:

Withdraw payment from my account 5 days before due date.

Withdraw payment from my account on due date.

To sign up for ZapCheck, fill out this form, print it and return it along with a voided check to:
Be sure to keep a copy of the form for your records.