Fillable Direct Deposit Signup/change Form printable pdf download

Direct Deposit Signup/Change Form

WORKERS: Retain a copy of this form for your

WORKER – REQUIRED INFORMATION

records. Return the original to your employer.

PLEASE PRINT IN BLACK INK ONLY

EMPLOYERS: Return this form to your local

Worker Name ___________________________________

Paychex office.

Last four digits of Social Security Number ___ ___ ___ ___

COMPLETE TO ENROLL OR CHANGE ENROLLMENT IN DIRECT DEPOSIT – PLEASE PRINT IN BLACK INK ONLY

Bank Account

Type of

Bank Name

Deposit Type (check

Change My Deposit

Number*

Account

one):

Amount to:

 Checking

 Remainder of Net

 Remainder of Net Pay

 Savings

 _____ % of Net

Pay

 _____ % of Net

 Specific Dollar Amount

 Chase Pay

If Chase Pay Card Plus, fill

 Specific Dollar

$ _____________ .00

Card Plus

out attached application.

 Remove from Direct

Amount $ _______ .00

Deposit

 Checking

 Remainder of Net

 Remainder of Net Pay

 Savings

 _____ % of Net

Pay

 _____ % of Net

 Specific Dollar Amount

 Chase Pay

If Chase Pay Card Plus, fill

 Specific Dollar

$ _____________ .00

Card Plus

out attached application.

 Remove from Direct

Amount $ _______ .00

Deposit

Please attach one of the following for Checking or Savings accounts (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)

*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information

specific to your account.

WORKER CONFIRMATION STATEMENT

PLEASE PRINT IN BLACK INK ONLY

I authorize my employer to deposit my wages/salary into the bank accounts specified above. My signature below indicates

that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize Paychex

Business Solutions, Inc. to make direct deposits into the named account.

Worker Signature _______________________________________________________ Date _____________________

Accountholder Signature _________________________________________________

(if worker’s name does not appear on bank documentation)

EMPLOYER SECTION ONLY

PLEASE PRINT IN BLACK INK ONLY

Company Name __________________________________________________________________________________

Office/Client Number _______________________________________________________________________________

Federal ID Number (last 4 digits) ___ ___ ___ ___

If bank documentation provided is different from what is listed above, the following must be completed by the employer:

I confirm that the above named employee has added or changed a bank account for direct deposit transactions processed by

Paychex Business Solutions, Inc. and provided valid documentation.

Employer Signature ________________________________________________________ Date _________________

Professional Employer Organization (PEO) Services are sold and provided by Paychex Business Solutions, Inc. and its affiliates. DP0015 1/11

Direct Deposit Signup/change Form

Related Articles

Related forms

Related Categories