Public Partnerships Home Care LLC
17 Plaza Dr. Latham, NY 12110
Fax: 1-833-951-0828
Payment Method Form
Personal Assistant Name: PPL ID:
_______________________________________________ ____________________
(First name, Last name)
The purpose of this Payment Method Form (Form) is for you, the Personal Assistant (PA), to tell
Public Partnerships LLC (PPL) how you want to be paid.
You can be paid in one of four ways:
• Through direct deposit to your bank account,
• Through a third-party money app, such as Venmo or Chime
• By an existing debit card that you already have, or
• By a new debit card that PPL will obtain for you.
IMPORTANT:
• PPL will pay you by paper check until your payment method is set up.
• This is because it takes one to two pay periods for a new payment method to become
active.
If you need to update your bank account, or details about your third-party money app, you must
submit a new Form.
Choose Your Method of Payment (Select one):
☐ Direct deposit to a Bank Account or Third-Party Money App
Account type (select one): ☐ Bank Checking Account ☐ Bank Savings Account
☐ Third-party money app
Bank or money app name: ____________________________________________________
Payment Method Form V1O New York State | CDPAP
Routing number: _________________________________
Account number: _________________________________________________
☐ Direct Deposit to An Existing Debit Card
Routing number: _________________________________
Account number: _________________________________________________
☐ Deposit to New Debit Card:
If you select a new debit card as your payment method, PPL must have a correct address on
file for you. If you work for more than one consumer, all payments will be on one debit card.
Pay stub:
Your pay stub is available through:
• Mail,
• PPL@Home, or
• The PPL mobile app called Time4CareTM
If you would like to receive your pay stub electronically, please check the below box.
☐ I opt-out of receiving paper copies of my paystubs. I will access my pay stubs
through PPL@Home or Time4Care . TM
Agree and sign:
By signing this form below, I confirm that:
• I have read all of this Payment Method Form.
• The details I have provided are accurate and complete.
• Based on my choices above, PPL will deposit my payment directly into my bank account,
into a third-party money app, or onto a debit card.
• If I fail to give complete and accurate details on this Form:
• My paychecks may be delayed, and
• My paychecks may be deposited in error.
• If my paycheck is deposited in error:
Payment Method Form V1O New York State | CDPAP
• PPL will withdraw from my account the incorrect deposited amount.
• I understand that PPL cannot withdraw the money from my account if:
• My account is closed, or
• Does not have enough money in it.
• If my paycheck is deposited in error and PPL cannot withdraw the money from my
account, PPL will withhold future payments owed to me until the incorrect deposited
amounts are repaid.
• If I need to change my payment method or update my payment details, I will need to
complete a new Form.
Personal Assistant Signature: Date:
__________________________________________________ __________________
Personal Assistant Name (please print):
__________________________________________________