Monon Telephone Company Inc.® Direct Credit Card Charge Plan

Application and Authorization

HOW THIS WORKS: By completing and signing this form, you are authorizing Monon Telephone Company Inc.® ("Monon") to directly charge your credit card, to pay your Monon telephone bill. You will receive a monthly statement indicating the amount that will be charged. You will have at least 10 days to review the statement for accuracy. If you have concerns or questions about the charges on the statement, you must contact us by the 15th of the month. We will charge the amount shown on the statement to your credit card on or after the 16th of each month. There will not be a late charge if we make the deduction before we prepare the next month’s bill. All deductions will be made prior to the next month’s bill. You will receive notification informing you that activation of direct credit card charge has been completed. Until you receive such notification, you should continue to pay any paper bills that you receive.

IMPORTANT INFORMATION: Credit Card charges will be initiated by Monon to pay Monon telephone bills. The charge will constitute your receipt for the transaction(s). No payment to Monon will be deemed made unless and until Monon receives actual credit. Monon reserves the right to refuse or terminate electronic payment services. You may terminate this agreement at any time by notifying Monon in writing or by calling (219) 253-6601 and speaking to a Monon Representative. Allow 5 business days for the termination to take effect. If corrections of the entry are necessary, it may involve an adjustment to your account.

CUSTOMER INFORMATION (Please Print):

Name:_______________________________ Telephone Number:___________________

Address:________________________________________________________________

City:_________________________ State:____________ Zip Code:_________________

ACCOUNT INFORMATION:

Card #__________________________________________ Exp.Date_____/________

Is this a request to change account information on a previously activated direct withdrawal?

(check one):

AUTHORIZATION:

By signing below, I hereby authorize Monon Telephone Company Inc.® to charge my Credit Card upon the above terms. I also affirm that I have credit in the above-listed account to cover the monthly withdraws.

Signature_______________________________________Date_______________________