Direct Deposit Form (Xincon) (Compliance)

FOR YOUR FILES ONLY
Authorization for Direct Deposit - Employee Form
This authorizes XINCON HOME-HEALTHCARE SERVICES INC (the "Company") to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated below and to other accounts I (we) identify in the future (the "Account" This authorizes the financial institution holding the Account to post all such entries.

Note: Enter your company name in the blank space above.

Account#1

Account #1 Type: CHECKING
EMPLOYEE BANK NAME
BANK ROUTING #(ABA#)
ACCOUNT#
100% NET PAY

PERCENTAGE OR DOLLAR AMOUNT TO BE DEPOSITED TO THIS ACCOUNT

This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it.
SIGNATURE

Clear
PRINTED NAME
EMPLOYEE ID#
DATE

MonthDayYear
Date
Should be Empty: