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, fill out the form below and submit along with an uploaded voided check.

I authorize CHA to charge my monthly payment 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 I understand the funds will be withdrawn on the tenth day of each month and that it is my responsibility to ensure sufficient funds are in my account at that time.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 changes in my membership 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 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.

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 upload size: 15MB