CHA ACH Enrollment Form - Donations 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. Full Name * CHA Membership Number (if applicable) Email * Phone Bank Routing Number (9 digits) * Bank Account # * Account Type * Checking Savings Amount of monthly donation: $ I authorize CHA to charge my monthly donation to the bank account number shown above. I understand the funds will be withdrawn on or around the 15th day of each month and that it is my responsibility to ensure sufficient funds are in my account at that time. This authority will remain in effect unless I instruct CHA to change or cancel it, or if my payment is returned because of insufficient funds or account closure, at which time CHA may discontinue this service at their discretion. Future authorization must be in writing and must be received by CHA by the 20th of the month prior to the effective month. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of the U.S. law. Please attach a voided check from the bank account to be debited for your monthly donation. Signature * signature keyboard Clear Upload Voided Check * Drop a file here or click to upload Choose File Maximum file size: 15MB Submit If you are human, leave this field blank.