EmailMe Form - Authorization to use Client Credit / Debit Card

EmailMeForm

Name of Client receiving home care services from Home Instead Senior Care *
Acknowledgment *
I acknowledge and allow for Home Instead Senior Care employees to use credit/debit card solely for purposes of purchasing items needed by aforementioned Client
Date this agreement is being signed *
MM / DD / YYYY
Name of Person filling this out *
Email of party filling this out
Telephone # *
Relationship of Person filling this out to Client *
Self (I am the Client)
Authorized Party using Client's Debit or Credit Card account
Third Party paying on behalf of client (cardholder)
Other
Type of Card
Name on the Card *
Last 4 numbers on the Card # *
NO CASH WITHDRAWALS

I (the undersigned) understand that through this instrument I am signing, I am responsible for telling the Home Instead staff who receives the debit or credit card that

(a) they are only authorized to make the specific purchases asked
(b) NO cash withdrawals for any purpose are to take place *
SHOPPING LIST & RECEIPTS

I (the undersigned) understand that I am responsible for assuring that the Home Instead staff who receives the debit or credit card

(a) is given a specific list of items to purchase
(b) gives me all receipts for all purchases made with such card

I (the undersigned) am responsible for checking receipts and comparing to the shopping list given.

I (the undersigned) understand that Home Instead does not engage in, nor is responsible for any type of bookkeeping, logging or receipt holding. *
MONTHLY STATEMENTS

I (the undersigned) commit to reviewing all statements every month as soon as they are available and I will review with the Home Instead office (in addition to the staff member using the card) any and all discrepancies to assure that if there are any charges or withdrawals that I feel are not authorized, I will raise them within 2 weeks of the statements being made available *
Signature

By signing my name in this field I am stating that I have read, understand and agree to the terms set forth within this contract. *
Clear
Use your finger or the mouse to sign
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