Autopay Authorization Form
  
Follow These Simple Steps...
1.  Complete this form 2.  Enclose VOIDED check issued by a U.S. financial institution.
        (no deposit slips)
 
Mail to:  Intermountain Gas Company, Attn: AutoPay, PO Box 7608, Boise, ID 83707-1608
Fax to:  208-377-6081 (completed form and voided check)
Scan and email to: customerservice@intgas.com
 
Customer Information (please print):
Intermountain Gas Account Number: (11 digits)
Customer Name (as shown on bill):
Service Address:
City: State: Zip: Day Ph #: ( ) - -
  Home Ph#: ( ) - -
Use this area to sign up a second Service Address:
Intermountain Gas Account Number: (11 digits)
Customer Name (as shown on bill):
Service Address:
City: State: Zip: Day Ph #: ( ) - -
  Home Ph#: ( ) - -

(Please use a separate AutoPay Authorization Form for each checking account.)

Name of Financial Institution:
                                                            Drawn from Checking Account Only

I authorize Intermountain Gas to instruct my financial institution to make my Intermountain Gas payments from the checking account listed above. I understand this program is voluntary, and if at any time I decide to discontinue my participation in this payment service, I will provide Intermountain Gas a 30-day written notice via email, postal mail or fax.

Don't forget to include a voided check! 

Signature:                                                                            Date:                                           

   
Print additional copy for your records