Direct Deposit Authorization – Life Time Skill Home

Name(Required)

First Name Last Name

Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Email(Required)

Work Phone(Required)

Social Security Number(Required)

What would you like to do?

Create new direct deposit account.

Change my direct deposit information.

Cancel my current direct deposit.

Name of Institiution(Required)

Type of Account

Checking

Saving

Account Owner

Self

Joint

Other

Account Number(Required)

Routing Number(Required)

Verify Account Number(Required)

Verify Routing Number(Required)

I UNDERSTAND THAT I MUST SUBMIT A NEW DIRECT DEPOSIT AUTHORIZATION FORM TO THE PAYROLL DEPARTMENT IF I CHANGE BANKS AND/OR ACCOUNTS OR ADD AN ADDITIONAL ACCOUNT.

check(Required)

I Understand

I authorize Lifetime Skill Home Healthcare Services Foundation to transfer the full amount of my salary, after tax deductions, to the financial institution(s) named above for deposit to my account(s). I understand that if I close my account(s), I will not receive a salary payment until my bank returns the funds to Skill Home Healthcare Services Foundation. Lifetime Skill Home Healthcare Services Foundation is authorized to terminate this agreement without notice if legally obligated to withhold any part of my salary. In the event my employer deposits funds erroneously into my account, I authorize Lifetime Skill Home Healthcare Services Foundation to debit my account for an amount not to exceed the original amount of the credit. This authorization remains in effect until I notify Lifetime Skill Home Healthcare Services Foundation Payroll Office in writing.

check(Required)

I Understand

I have verified the transit/routing and account information and understand the named financial institution will receive and deposit sums for the above-named payee in accordance with NACHA Rules and Guidelines.

check(Required)

Transit/Routing and Account Number Verified

Employee Signature:(Required)

Date(Required)