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Integrated Medicine Alliance, P.A.

ADP PAYROLL SERVICES ELECTION FORM

As an employee of Integrated Medicine Alliance, P.A., you have the option to elect to have your payroll funds electronically deposited to your checking/savings account. If you choose to participate in direct deposit, your payroll funds will be deposited to your designated account(s) and be available for your use on the payroll pay date (semimonthly on the 15th and 30th of the month).

If you choose to participate, you must attach (to this form) a copy of a voided check from the account you have designated. It will take approximately 1-2 pay periods to complete the account set up and testing. In the interim, you will receive a paper payroll check on the payroll pay date (15th and 30th) that has been signed, stuffed and sealed in an envelope by ADP. When the direct deposit account set up is completed, you will receive a voucher/voided check on every payroll pay date that looks exactly like a payroll check.

You must indicate your decision below and sign where noted, regardless of whether you choose to participate or decline the ADP direct deposit payroll service.

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______I would like to participate in the ADP direct deposit payroll service and hereby authorize Integrated Medicine Alliance, P.A. to deposit payroll funds due me on the 15th and 30th of the month to the following bank account(s). I have attached (to this form), a copy of a voided check or bank letter for my designated account(s).

Primary Account

Employee Name (Printed):________________________________________________________________

Account Title (if not employee name):________________________________________________________

Name of Primary Bank: __________________________________________________________________

Routing Number:___________________________ Account Number:______________________________

Type of Account:___________________________ Balance of Paycheck

Checking/Savings

Second Account

Name of Second Bank:___________________________________________________________________

Routing Number:___________________________ Account Number:______________________________

Type of Account:___________________________ Specific Dollar Amount _________________________

Checking/Savings

____________________________________________________ _________________________________

Employee Signature Date

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______I decline to participate in the ADP direct deposit payroll service and understand that Integrated Medicine Alliance, P.A. will issue a check to me for payroll funds due me on the 15th and 30th of the month.

Employee Name (Print):_________________________________________________________________

____________________________________________________ ______________________________

Employee Signature Date

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