This government document is issued by State Health Benefit Plan for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://shbp.georgia.gov/document/document/ach-funds-pull-debit-banking-information-form-boe/download&sa=U&ved=2ahUKEwjC4b3mmeOLAxXSV6QEHTVYNSk4RhAWegQIChAB&usg=AOvVaw1xODMRxF0NUEjpX9_9Xnsd