Paydata Employee Set Up Form printable pdf download

PayData Employee Set up Form:

Company # _______

Company Name:

Date: _______________

* REQUIRED FIELDS

Employee # __________

New Hire _____ Rehire _____ Employee changes ______

*SS#

*Employee Full Name

*Address

*City, State, Zip

Employee Email Address

Date of Birth: ________________ *Date of Hire: _____________

*Gender: M or F

Termination Date: ____________________

Salary Y or N

Per Pay Salary Amount $____________________ Div/Branch/ Dept: __________________________

Rate of Pay: __________

Override Div/Branch/ Dept __________________________ Full or Part time

Rate of Pay: __________

Override Div/Branch/ Dept: __________________________

*Federal Withholding: M or S

# of Exemptions

____

Add Fed $ ____________

Work Visa: N o r YES # ______________________

*Withholding State:

Override State Withholding: (Specify State) _____ M or S # of Exemptions

Add SWT $_________

* VT Employee Health Insurance Coverage Status:____ Not Covered _____Covered by Company Plan ____Covered by Spouse Plan_____Other

Time Off Banks

Begin Balances

Notes

Deduction Name

Per Pay Amount

Per Pay Percentage

Notes

Direct Deposit Information:

Bank Name

Account Type

Bank ABA#

Account #

Amount or

(C or S or HSA)

Full NET

PAY

I (we) hereby authorize and request the COMPANY, to make payment of any amounts owing to me (either of us) by initiating credit entries to my (our)

account indicated below in the bank named below, hereinafter called BANK, and I (we) authorize and request BANK to accept any credit entries initiated by

COMPANY to such account and to credit the same to such account without responsibility for the correctness thereof.

I (we) authorize and request COMPANY to effect repayment to COMPANY for amounts owed it because of a prior erroneous credit initiated to my (our)

account if prior to the correcting entry, the COMPANY has sent or delivered to me written notice of the correction and the reason therefore; and the correcting

entry is transmitted in such time as to be delivered or made available to BANK before midnight of the tenth day next following settlement for the erroneous

entry.

It is understood that this agreement may be terminated by me (either of us) at any time by written notification to COMPANY or BANK. Any such notification to

COMPANY shall be effective only with respect to entries initiated by COMPANY after receipt of such notification and a reasonable opportunity to act on it.

Any such notification to BANK shall be effective only with respect to entries credited to my (our) account by BANK after receipt of such notification and a

reasonable time to act on it.

I (we) recognize, acknowledge and accept this service is being provided for my (our) convenience. As such, I (we) agree to hold the COMPANY, PayData

Payroll Services, Inc., each participating bank and NACHA harmless from any claim incident to the operation of this plan, arising from any act or omission by

the COMPANY and/or PayData Payroll Services, Inc. and their employees, including without limitation any claim based on alleged loss as a result of non-

credit of any deposit, and any claim which may be made by any depositor as a result of the rejection of any of his/her debits because of insufficient funds

arising from the failure to credit deposits to his/her account.

PRE-NOTE: PayData highly encourages that all account go through the pre-noting process. The ONLY times when you should say Pre-note NO is if you are

setting up a Direct Deposit account that will be used with an HSA

Employee Signature: ______________________________________________________________

Submitted by: ____________________________________________________________________