Service Contract - Kindred Home Care

Sign your Service Contract

To complete this form you need the service contract PDF that was emailed to you, and if applicable your bank account information and a void cheque.
Contract ID:*
Acknowledgement
By signing below, I agree to the terms and conditions set forth in the service contract attached.
Upload the Service Contract to which you are agreeing here:*
Max. file size: 256 MB.
Name:*
Date:*
DD slash MM slash YYYY
Sign Here:*
Are you or your family members paying for any portion of your services with Kindred Home Care?:*
Choose yes if you are paying for all or some of your hours or if you are required to pay a client contribution amount for hours subsidized by the Department of Social Development.
Pre-Authorized Payment Agreement - Personal
Your Authorization as Payor to Charlotte County Human Resources (Kindred Home Care)
Payer Information
Name:*
Email:*
Street:*
City:*
Province:*
Account Details
Transit Number:*

The transit number (five digits) identifies which branch you opened your account at (often called your home branch).
Financial Institution Number:*

The institution number (three digits) identifies which bank you use (i.e., TD, RBC, Scotiabank, etc).
Account Number:*

The account number (seven to twelve digits) identifies your individual account.
Please upload an image of a void cheque so that we can verify the information you’ve submitted:
Max. file size: 256 MB.
Payment Details
I/We, the chequing account holder(s) signing below, authorize Kindred Home Care to debit my account for regular monthly recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our account.

Typically, the payment will be debited on the 15th day of the month (Note: if service began partway through the first month, Kindred Home Care will debit the amount somewhere between the 15th and the last day of the month). I understand that I will be notified if the debit amount needs to be adjusted.

I/We, agree and understand that if any debit authorized under this agreement is returned unprocessed or is rejected for any reason, Kindred home Care may re-present the debit for authorization and may initiate another debit in the amount of its returned payment plus a non-sufficient fund fee of $25.00.

I agree to waive any legislative or regulatory requirement for pre-notification.

I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain more information about your recourse rights, you can visit www.payments.ca.

This authority is to remain in effect until Kindred Home Care has received written notification from me/us of its change or termination. This notification must be received at least ten (10) business days before the next debit is scheduled. I/We may obtain a sample cancellation form, or more information on my/our right to cancel a PAD agreement at www.payments.ca.
*
- I authorize Kindred Home Care to Debit my bank account as outlined in the payment terms of this agreement.
Account Holder Signature:*
Joint Account Holder Signature:
For joint accounts, all account holders must sign if more than 1 signature is required on cheques issued against the account.
Name
This field is for validation purposes and should be left unchanged.

Sign your Service Contract

Acknowledgement

Pre-Authorized Payment Agreement - Personal

Payer Information

Account Details

Payment Details