Direct Deposit Agreement Form

Name

This field is for validation purposes and should be left unchanged.

Authorization Agreement

I hereby authorize Royal Home Care Services to initiate automatic deposits to my account at the financial institution named below. I also authorize Royal Home Care Services to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold Royal Home Care Services responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until Royal Home Care Services receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.

Account Information

Name of Financial Institution

Routing Number

Account Number

Account #

Checking

Savings

Signature

Authorized Signature (Primary)

Date

Authorized Signature (Joint)

Date

Please attach a voided check or deposit slip and return this form to the Payroll Department.