Please fill in the information and sign below.
EasyPay Authorization Agreement for Automatic Bill Payment
Name ________________________________________________________________________________
(exactly as it appears on bank/credit card account)
Cox Account # ________________________________________________________________________
Street Address ________________________________________________________________________
City __________________________________________________ State ____________ Zip __________
Home Phone _________________________________________________________________________
Email ________________________________________________________________________________
Select Payment Type: Bank Credit Card
If Bank is checked above, please fill out the following:
For Checking Account (PLEASE INCLUDE A VOIDED CHECK) or Savings Account
Routing and Account # __________________________ – _____________________________________
Bank Name ___________________________________________________________________________
City/State of Bank _____________________________________________________________________
If Credit Card is checked above, please fill out the following:
Account # ____________________________________________________________________________
Master Card
Visa
Discover
American Express
Expiration Date:_______________________________
I hereby authorize Cox Communications to charge or debit my credit card/checking/savings account indicated above for the
total amount due each month for my Cox services. I understand that I can cancel my participation in this program upon written
notice to Cox Communications, allowing a reasonable time for action on my cancellation notice. I understand that I have the
right to stop automatic payment by notifying my financial institution prior to the time my account is charged or debited. I also
understand that Cox Communications and/or my financial institution can cancel my enrollment in this program at any time.
I understand that Cox Communications may charge me a fee for any unpaid charges returned to Cox and/or denied by my
financial institution for Cox services.
Signature ___________________________________________________ Date ___________________
Please allow 30-60 days after enrollment for EasyPay automatic payments to begin. Look for this message on your bill
statement: Please do not pay. Your account will be debited when due. Until you see that message, continue to pay your
Cox bill as usual. Cox services not available in all areas. Customer may stop an EasyPay payment by timely notifying his or her
financial institution before account is debited or charged. EasyPay program enrollment will remain in effect until revoked by
customer, Cox Communications or customer’s financial institution. Customer must notify Cox Communications in writing of
any decision to cancel enrollment in EasyPay program, allowing reasonable time for action on cancellation notice. Certain
restrictions may apply. EasyPay is a service mark of Cox Communications. ©2008 Cox Communications, LLC. All rights reserved.
12
12
