Direct Deposit/Authorization Form - New England Home Health Services

Name*

First Middle Last

Transaction*

Social Security Number*

Phone Number*

Effective Date*

Name Of Financial Institution*

Account Nunber*

Routing Number*

Type Of Account*

Account Holder*

Authorization*

I hereby certify that I have read and understand the direct deposit terms outlined in the employee handbook. I also understand that if I have a joint account, the other holder must also agree to the direct deposit terms. By signing this agreement, I request and authorize New England Home Health Services, Inc. and New England Nurses, Inc. to initiate credit entries to the account indicated above for the purpose of payment of my payroll earnings. I also authorize NEHHS and NEN to initiate debit entries and adjustments for any credits made in error.

Email Advice Request/Authorization

I hereby certify that I have read and understand the following conditions: The maintenance, accuracy, privacy, and protection of my email address above, is entirely the employee’s responsibility. NEHHS/NEN is not responsible for bad, incomplete, or inaccurate transmissions. NEHHS/NEN reserves the right to cancel, stop, or change email transmission (including email addresses) at any time, with or without notice. I hereby and certify and understand the above and give permission to NEHHS/NEN to transmit payroll advice(s)/stub(s) weekly to the email address provided by employee or employer.

Signature

Name*

First Last

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