Form Dp0002 - Direct Deposit Enrollment/change Form
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Direct Deposit Enrollment/Change Form
Ability Care Partners Inc.
N/A
Company Name____________________________________ Client Number____________________
Employee/Worker Name_____________________________ Employee/Worker Number__________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer.
EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a
copy
of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of
Routing/Transit
Checking/Savings
Financial Institution
I wish to deposit (check one):
Account
Number
Account Number*
(“Bank”) Name
_____ % of Net
Checking
Specific Dollar Amount $_______ .00
Remainder of Net Pay
Savings
_____ % of Net
Checking
Specific Dollar Amount $_______ .00
Remainder of Net Pay
Savings
One of the following is required to process this enrollment (check one):
Voided check with name imprinted (no starter checks)
Deposit slip (only accepted if the verbiage “ACH R/T” appears before the routing number)
Bank letter or specification sheet (the signature of your local bank representative MUST be included)
Other Bank Documentation from your Financial Institution – If this box is checked the employer must sign this
confirmation:
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed
by Paychex, Inc.
Employer Signature
:_____________________________________ Date _______________
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information
specific to your account.
COMPLETE IF
CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Financial Institution
Checking/Savings
Routing/Transit Number
Change My Deposit Amount to:
(“Bank”) Name
Account Number*
From _____% to____% of Net
From $ ______.00 To
$_____.00
Remainder of Net Pay
From _____% to____% of Net
From $ ______.00 To
$_____.00
Remainder of Net Pay
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit transactions
I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder or
.
have the authority of the accountholder to authorize my employer to make direct deposits into the named account
Employee/Worker Signature _______________________________________ Date ________________
Note:
Digital or Electronic Signatures are not acceptable.
DP0002 12/14
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Parent category: Business