Resource Center for Independent Living (RCIL) Payroll &
Reimbursement Authorization Form
Personal Assistant’s Information: (print and complete all fields)
First Name: BERNICE Middle Last Name: EDWARD
Name:
Date of Birth: 12/09/1961 Department/Program: CDPAP Last Four Social
Security #:
Mailing Address: 77 LINDEN BLVD APT 3F Apt # (if applicable):
City: BROOKLYN State: Zip Code: 11226
NY
Home Phone: Mobile Phone: Email Address: toyesaolicesar@[Link]
Physical Address (Required if PO Box listed above): Apt # (if applicable):
77 LINDEN BLVD APT 3F
City: State: Zip Code: 11226
BROOKLYN NY
Payment Election: I hereby authorize RCIL to distribute my paycheck and
reimbursements as follows:
Direct deposit into my bank account ☐
Direct deposit onto my
preferred Debit Card
*You may receive your first paycheck in the mail as your bank account information for
direct deposit is being verified*
You must attach the following documents (depending on the type of account
you elect):
Checking: Voided Check or a statement from your bank, on bank letterhead, containing your
name and account information.
Savings: Savings Deposit Slip or a statement from your bank, on bank letterhead, containing
your name and account information.
Debit Card: Electronic information regarding your account, including name and account
information.
Routing Number: 124303120
Account Number: 996454002077
Type of Account: ☐ Checking ☐ Savings ☐ Debit Card
If you do not elect deposit to your personal account, one of the below will be selected
for you.
☐ Direct deposit onto the Wisely Pay by ADP card
This Wisely Pay card will be issued by RCIL’s payroll service provider ADP. This card will be
mailed to your mailing address listed above. You will be required to activate your card
immediately upon receipt.
☐ Direct deposit onto the Wisely Check by ADP (ADP will mail you a card and checks)
I understand that although I will be enrolled in the Wisely Program, I am not required to activate
or use a Wisely Pay card to use the Wisely Check to receive my full net pay. Wisely Check will be
the default payment method if no other wage payment method is selected above.
If I elect to use the Wisely Check, I understand that each payday I will need to make the check
payable to myself for my full net pay, date the check, call to authenticate the check and write the
Updated: 12/2019; 03/2022; 07/2022; 11/2023
Resource Center for Independent Living (RCIL) Payroll &
Reimbursement Authorization Form
authentication code on the check prior to being able to cash the Wisely Check.
Consent to Deposit Payment:
Personal Assistant’s Signature: Date: 03/20/2024
Updated: 12/2019; 03/2022; 07/2022; 11/2023