Direct Deposit Request Form

* = Required Information

Direct Deposit Request

Directions: Attach a voided check or pre-printed form from the bank, sign and date the form from the bank, and then fax the form to the A Helping Hand Senior Care Services LLC. Office: 612-255-3115. Hand-written routing and account numbers cannot be accepted.

Attach Voided Check Here

Routing Number *

Account Number *

Bank Name *

Checking

Savings

Full Amount *

Other Amount *

By signing below, I authorize A Helping Hand Senior Care Services LLC to deposit the requested amount of my paycheck into the above account. Please note that the Direct Deposit Request form needs to be submitted no later than 5pm on Monday of payroll week.

Full Name *

Date *

Printed Name *