PBHA Direct Deposit Form
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Harvard ID (HUID):
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If you don't have one, please enter N/A.
Legal Name:
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Email Address:
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Email
PBHA Program Name:
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For example: Term - FIO Afterschool
Bank Name:
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Checking or Saving:
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Bank Routing Number:
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Bank Account Number:
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Please upload Bank Information:
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A VOID Check/Bank Account Confirmation Letter
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By signing below, I authorize Phillips Brooks House Association (PBHA) to electronically deposit payments to the account information indicated in the attached document. In the event that funds are erroneously deposited to the undersigned's bank account, Phillips Brooks House Association (PBHA) is authorized to debit the account in the amount of the erroneous deposit with prior written or verbal notice to the undersigned.
Electronic Signature
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