Authorization for Direct Deposit- Employee Form

Form A

FOR YOUR FILES ONLY
Authorization for Direct Deposit- Employee Form
This authorizes XINCONHOME-HEALTHCARESERVICESINC
(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)identifyinthefuture(the"Account"). This authorizes the financial institution holdingthe Account to post all such entries.

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

Account#1
Account #1 Type: CHECKING
支票樣本說明
Check Sample
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.
PRINTED NAME*
EMPLOYEE SSN#*
Signature*

Clear
Please submit your void check picture
Today's Date*

MonthDayYear
Date
Should be Empty:

Form A