CHA ACH Enrollment Form - Monthly Shares

Christian Health Aid
Automatic Payment Authorization Form - Monthly Shares

To enroll in the automatic payment program and have your monthly shares deducted from your bank account, please fill out the information below and return this page with a voided check to CHA.

I authorize CHA to charge my monthly share to my bank account number shown above. This also includes authorization to charge to my bank account any past due balance on my CHA account. I understand the funds will be withdrawn on or around the 10th day of each month and that it is my responsibility to ensure sufficient funds are in my account at that time.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 due to membership changes with CHA, 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 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.

I wish to receive future sharing notices and other billing information (including ACH change notices) via:
     (if no box is checked, correspondence will default to email.)
Please attach a voided check from the bank account to be debited for your membership shares.

Maximum file size: 15MB