Employee Direct Deposit Access Card Application Form printable pdf download

PAYCHEX

Employee Direct Deposit

Access Card Application

Employee Instructions:

PAYCHEX

Use Only

1. Complete the employee required information section.

2. Complete the Direct Deposit, Access Card, of both

sections to specify where you want your pay deposited.

Account No. _______________________________

3. Sign the bottom of the form.

4. Retain a copy and return the original to your employer.

Employer Instructions:

1. Complete the employer required information section.

2. Return this original form to your local Paychex office

Rounting/Transit No. _________________________

(no copies or faxes, please)

EMPLOYEE - Required information

EMPLOYER - Required information

Please Print

Employee Name _____________________________

Client Name _________________________________

Social Security No. ___ ___ ___/___ ___/ ___ ___ ___ ___

Branch/Client No. ___ ___ ___ ___ / ___ ___ ___ ___

Preferred Language

English

Spanish

Federal ID No. _______________________________

Complete for DIRECT DEPOSIT

I would like my wages/salary deposited to the bank account attached

Checking

Savings

Bank Name _______________________________________

Bank Name _________________________________

(Attach a void check, bank letter, or specification sheet.

(Attach only a bank letter or specification sheet.

No deposit tickets allowed)

No deposit tickets allowed.)

I wish to deposit ( check one):

Entire Net Pay

_____% of Net

Specific Dollar Amount $ _____ .00

Complete for ACCESS CARD

I would like my wages/salary deposited to an Access Card account at NBD Bank. I agree to the terms and conditions of the

Paychex Access Card Program (including the $1.50 monthly maintenance fee and the $1.00 per ATM withdrawal fee) as set forth in

the materials received by me with this application, or to be received by me prior to my use of the Access Card.

Entire Net Pay

_______% of Net

Specific Dollar Amount $ ________ . 00

Please print the address where the Access Card, PIN and statements should be mailed.

Address _________________________________

City __________________

State ___________

Zip _____________

Home Phone No. (__ __ __) __ __ __ - __ __ __ __ Work Phone No. (__ __ __) __ __ __ - __ __ __ __ Date of Birth __ __/__ __/__ __

Additional Card Requested

Additional Card Holder Name ___________________________________________________

Additional Card Holder Social Security No. __ __ __ / __ __ / __ __ __ __

I hereby authorize my employer, Godwin Corporation (hereinafter COMPANY): to deposit any amounts owed me by initiating credit entries to my account the financial institution

(hereinafter BANK) indicated above. Further, I authorize BANK to accept and to credit entries indicated by COMPANY to my account, in the event that COMPANY deposits funds

erroneously into my acccount, I authorize COMPANY to debit my account for an amount not to exceed the original amount of the errouneous credit.

For my convienence, I request that Paychex, Inc. (hereinafter Paychex) directly deposit my wages/salary earned from my employer, into my bank account. I, understand that deposit

of bank, if within 30 days of Paychex making the deposit into my account, my employer does not make available to Paychex the funds that were advanced to make the deposit into

my account. I authorize Paychex to charge my account to recover said advance. I agree to hold Paychex harmless from loss and to indemnity it, limited to the amount of the

deposit.

Any dispute arising out of or in connection with this agreement, if not otherwise resolved, shall be determined by arbritation in Rochester, New York, in accordance with the Rules

of the American Arbitration Association, and it is the expressed desire of both parties that the prevailing party be awarded costs and attorney's fees and that the award be entered

as a judgement in any jusidiction in which non-prevailing party does business.

This authorization is to remain in full force and affect until COMPANY and BANK have received written notice from me of its termination in such time and in a manner as to

afford COMPANY and BANK a reasonable opportunity to act on it.

Employee Signature: ______________________________ Date: __ __/ __ __/ __ __ Return this original form to your employer.