Setup Direct Deposit – COTA Portal

Please complete this form to setup an account for direct deposit of funds. Please note, funding may be delayed until verification of direct deposit setup is complete.

Patient Name*

First Last

Primary Bank Account Holder's Name*

First Last

Name of Financial Institution*

Account Type*

Routing Number*

Account Number*

Attach an image of a voided check for the listed account*

Max. file size: 256 MB.

Direct Deposit Authorization Agreement*

I Agree to these terms and conditions

I hereby authorize the Children’s Organ Transplant Association to initiate automatic deposits to my account at the financial institutions named in this section. I also authorize the Children’s Organ Transplant Association to initiate withdrawals from this account in the event that a credit entry is made in error. Further, I agree not to hold the Children’s Organ Transplant Association responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until the Children’s Organ Transplant Association receives written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Children’s Organ Transplant Association.

Please enter your first and last name.*

First Last

Email Address*

Use your mouse or touchscreen device to sign your name in the box below.*

Direct Deposit Agreement