Dominion Direct Debit Authorization

Please print two (2) copies of this form, complete both, return one copy to Dominion Resources and keep the other for your records.

_____________________________________________
Address

_____________________________________________
City                             State                Zip

Your Bank Account Information (Print)
(Important: Verify #'s with your bank)

_____________________________________________
Your Bank Name

__ __ __ __ __ __ __ __ __
Bank Routing Transit # (always 9 digits)

_____________________________________________
Bank Account #

_____________________________________________
Bank Telephone #

What type of account will be debited? (Select one)

__ Checking Account - Enclose VOIDED CHECK

          or

__ Savings Account

$_______________Specify Amount

Note: Amount will be the same for each transaction

Deduction Agreement
(Check only ONE!)

Note: $40.00 minimum per transaction. Purchases are made on the 5^th & 20^th or next business day.

Please withdraw funds on:

__ 1^st or __ 15^th or __ 1^st & 15^th of each month or next business day.

AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENTS (DEBITS)

I (we) hereby authorize DOMINION RESOURCES, INC., herein after called DRI to initiate debit entries to my (our) checking/savings account maintained at the bank named above. I (we) understand that we may stop payment by written notification to DRI at least five (5) business days prior to the date scheduled for charging the account.

If you have any questions regarding the completion of this form, please call us between 9:00 am and 4:00 pm Eastern time (Monday through Friday) at 1-800-552-4034,  or write us at Dominion Resources, Inc. P.O. Box 26532, Richmond, VA  23262.

________________________________________
Signature                                                 Date

________________________________________
Signature                                                 Date

(______)________________________________
Daytime Telephone Number

If joint account, all owners must sign.

Social Security Number ____________________________

Account ID (Office Use Only) ____________________________