Christian Health Aid
Automatic Payment Authorization Form for Donations
To enroll in the automatic payment program and have your monthly shares deducted from your bank account, fill out the form below and submit along with an uploaded voided check.
Amount of monthly donation you wish to be withdrawn for each of the following:
Please attach a voided check from the bank account to be debited for your monthly donation.
I authorize CHA to charge my monthly payment to my bank account number shown above. I understand the funds will be withdrawn on or around the fifteenth day of each month and that it is my responsibility to ensure sufficient funds are in my account at that time.
I understand that if my total payment amount changes for any reason, I will receive notice from CHA and they will withdraw the new amount on the effective date of such change unless otherwise instructed by me.
This authority will remain in effect until I instruct CHA to cancel or change it. Future authorization must be in writing and must be received by CHA seven days prior to the first day of the effective month. I also understand that if my payment is returned for “Not Sufficient Funds”, CHA may discontinue this service at their discretion. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of the U.S. law.