New RHA Account

First Name

Middle Initial

Last Name

 

Employer Name

Effective Date  (Retire / Separation / Eligible Date)

 

Date of Birth

Gender      Male       Female

SSN

 

Street Address

Address (cont.)

City

State

ZIP

 

Cell Phone

Home Phone

E-Mail

 

Log-in Username

Log-in Password

 

Account to Deposit your Funds

Bank Name

Name on Account

Routing Number

Account Number

 

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