HRA GROUP - DIRECT DEPOSIT- ACH FORM

Enrollment or Change Form for Direct Deposit via ACH

Please print and complete ALL the information below.
Please check the applicable option*

EnrollChangeCancel
Member ID #
Name of Owner*

First NameLast Name
Phone #
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Corporation*
Name on the Account:*
Name of Bank*
Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account #*
9-Digit Routing #*
Type of Account*

CheckingSavings
Please attach a voided check for each bank account to which funds should be deposited.

HRA Group is hereby authorized to directly deposit to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.
Voided Check File Upload*

Voided Check Copy
Cancelof
Signature*

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Date

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Date