Alafia Authorization for Direct Deposit

Authorization for Direct Deposit
Select One*

NEW SETUPCHANGE/MODIFYCANCEL/STOP
Full Name*
Address*
City*
State*
Zip*
Primary Phone*
Alternate Phone
Email*
example@example.com
Social Security*
PLEASE ATTACH A DIRECT DEPOSIT FORM FROM YOUR FINANCIAL INSTITUTION OR A VOIDED CHECK

***YOUR NAME MUST BE ON THE ACCOUNT***
I AUTHORIZE INCARNATION HOME HEALTH SERVICES TO DEPOSIT MY PAY AUTOMATICALLY TO THE ACCOUNT(S) ON THE ATTACHED DIRECT DEPOSIT FORM, IF NECESSARY, TO ADJUST OR REVERSE A DEPOSIT FOR ANY PAYROLL ENTRY MADE TO MY ACCOUNT IN ERROR. THIS AUTHORIXATION WLL REMAIN IN EFFECT UNTIL I CANCEL IN WRITING AND IN SUCH TIME AS TO AFFORD INCARNATION HOME HEALTH SERVICE INC A REASONALBE OPPORTUNITY TO WORK ON IT.

PLEASE BE ADVISED THAT AFTER CHANGING YOU DIRECT DEPOSIT INFORMATION MORE THEN TWICE WILL RESULT IN YOU GOING ONTO PAPER CHECK PERMANATELY AND YOU WILL HAVE TO COME INTO THE OFFICE AND PICK UP YOUR CHECK.
Upload a copy of your voided check here*

Cancelof
***WE WILL NOT MAIL OUT ANY CHECKS***
IF YOU UNDERSTAND AND AGREE TO THESE TERMS PLEASE SIGN BELOW.
Employee Signature*
Date*

MonthDayYear
Date
Should be Empty:

Authorization for Direct Deposit