ACH Form - Health Insurance

Health Insurance - Co-Pay - Flexible Spending - Health Savings Account 

Authorization Agreement for Automatic Withdrawal of Funds

Below please use name of person filling out this form and email.

*First Name
*Last Name
*Church Number

District # - Church #

*Church Name on Bank Account
*Church Address on Bank Account
*Church City/State/Zip on Bank Account
*Routing Number

Routing # is located at bottom of check between the symbols |:  |:

*Account Number

*Please Debit Payments from
Checking Account
Saving Account

Please fax, scan or mail voided check (if using checking account for withdrawal) or savings deposit slip (if using savings account for withdrawal) .

Fax, Scan or Mail to Kerry Patles at,  FAX:  (978) 682-8227, New England Conference, 411 Merrimack St, Suite 200, Methuen MA 01844

You do not need to send a check or deposit slip if you are currently using  ACH and your bank account information has not changed.

Monthly Payments
Health Insurance

Enter $ amount.

Pastor's Premium CoPay

Enter $ amount.

Flexible Spending

Enter $ amount.

Health Savings Account (HSA)

Enter $ amount.

*Total Monthly Payment

Enter $ amount.

*Payment Date of Withdrawal

If you selected Other for Payment Date of Withdrawal please enter date below.

*Date of First Payment
*Date of Last Payment

I authorize New England Annual Conference and Vanco Services, LLC to process monthly debit entries from my account.  I also authorize the New England Annual Conference and Vanco Services, LLC to make changes to these deductions due to pastoral changes during the plan year.  This authority will remain in effect until I give reasonable notification to terminate this authorization, or until the specified end date.

*Electronic Signature

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
For Conference Office Use Only
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