ROACH ENERGY ELECTRONIC FUNDS TRANSFER
AUTHORIZATION FORM

I (we) hereby authorize Roach Energy Company (Roach Energy) to initiate electronic transfers from my (our) checking/savings account at the financial institution listed below. Transfers will generally occur on Friday, the week after the date of delivery or the provision of service. I authorize Roach Energy to make electronic transfers for the following items:

_____ Fuel Deliveries until further notice

_____ Heating and/or AC Service until further notice

The delivery invoice or service invoice will serve as notification of an electronic funds transfer. For transfers over $500.00 I (we) will receive a secondary notification. This authorization will remain in effect until I (we) notify Roach Energy in writing to cancel it. Roach Energy is further authorized to electronically transfer funds into my (our) account if necessary to correct an error. There is a $25.00 charge for transfers which do not clear due to insufficient funds.

(Name of Financial Institution)

(Address of Financial Institution - Branch, City, State & Zip)

Checking Account or Savings Account, Account Number

(Signature) (Date)

(Name - Please Print)

(Address - Please Print)

Phone E-Mail Address

Please attach a deposit slip or voided check for your account which contains the account number and financial institution routing number.

I authorize Roach Energy Company (Roach Energy) to keep my signature on file and to charge my MasterCard or Visa account as indicated below:

Check one: ________ MasterCard ________ Visa ________ Balances for Fuel deliveries and/or Services which are not paid within 60 days not to exceed $_________________.

_____ Fuel Deliveries and/or Services rendered at this time.

I understand that this form is valid unless I cancel authorization through written notice to Roach Energy.

Customer Name Cardholder Name

Customers Shipping Address Cardholder Billing Address

City	State	Zip	City		State	Zip
			Month	Year
Account Number			Expiration Date
			X
Date			Cardholder Signature