Membership Enrollment Form
Plan
Investments
Primary Member
Current Addresses
Secondary Member
Previous Addresses
Referral
Checklist
Step 0 of 8

General Enrollment Instructions:

  • Complete all required fields before continuing on to the next step. Required fields are marked with a red star image: Cannot be left blank
  • When you have entered all of the information requested, be sure to complete the additional items located on the 'Checklist' tab.
  • Hover your mouse over the field labels for content definition, entry requirements and valid data-entry examples.
Plan Choice

Investment Instructions:

  • We do not accept Credit Card or Debit Card payments.
  • Please submit Certified Check or Money Order payments via mail to:
    • USCCRA, LLC
    • 802 Michigan Ave.
    • Palm Harbor, FL 34683
  • Fields shown with a sliver/grey background are read-only.
Initial Payment Type
Monthly Payment Type
Monthly Payment Due Date / Draft Date (Preferred)

Primary Account Holder - Information:

  • We will also require you to submit your SSN (Social Security Number) after the enrollment process begins.

Primary Account Addresses:

  • Un-check the Residence Address box and enter another address if your you do not use your home address for billing purposes.
  • Also, be sure to enter the address printed on your checks if requesting the Bank Draft payment type.
Mailing Address
Residence Address
 

Check Address
 

Family Plan - Spouse Information:

  • The Spouse or Significant Other must reside at the same address as the Primary Account holder.
  • We will also require you to submit your Spouse's SSN (Social Security Number) after the enrollment process begins.
Previous Address
 

Spouse Previous
 

Referred By
Membership Agreement
 

Payment Agreement
 

Right to Cancel
 

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