Direct Deposit/access Card Signup Form
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1
2Paychex Use Only
Client Number ________________
Worker Number _______________
Direct Deposit/Access Card
PRS ________________________
Date________________________
Signup Form
Verified By___________________
Worker Instructions:
Employer Instructions:
1.
Complete the “WORKER - Required Information” section.
1.
Complete the “EMPLOYER - Required Information”
2.
Complete the Direct Deposit, Access Card, or both
section.
sections to specify where you want your pay deposited.
2.
Return this form to your local Paychex office.*
3.
Sign the bottom of the form.
*
See below for acceptable bank account documentation. Deposit
4.
Retain a copy of this form for your records. Return the
slips are not accepted.
original to your employer.
EMPLOYER – Required Information
WORKER – Required Information
PLEASE PRINT
PLEASE PRINT
Company Name ____________________________________
Worker Name ____________________________________
Office/Client Number
___ ___ ___ ___ / ___ ___ ___ ___
Federal ID Number
___ ___ ___ ___ ___ ___ ___ ___ ___
Complete for DIRECT DEPOSIT and Sign Below
I authorize my employer to deposit my wages/salary to the following bank account(s):
Bank Account #1
Checking
Savings
Bank Account #2
Checking
Savings
Bank Name _________________________________
Bank Name _________________________________
I wish to deposit (check one):
I wish to deposit (check one):
Entire Net Pay
Entire Net Pay
______ % of Net
______ % of Net
Specific Dollar Amount $ ______ .00
Specific Dollar Amount $ ______ .00
Please attach one of the following (check one):
Please attach one of the following (check one):
Voided check (deposit slips are not accepted)
Voided check (deposit slips are not accepted)
Bank letter or specification sheet*
Bank letter or specification sheet*
*See your local bank representative.
*See your local bank representative.
Complete for ACCESS CARD and Sign Below
I authorize my employer to deposit my wages/salary to an Access Card account. I agree to the terms and conditions of the
$2.00
$1.50
$3.00
Paychex Access Card Program including the
monthly maintenance fee, the
per ATM withdrawal fee, the
over-
$15.00
the-counter cash advance fee, and the
lost or stolen card replacement fee.
I wish to deposit (check one):
Entire Net Pay
______ % of Net
Specific Dollar Amount $ _______.00
Please print the address where the Access Card statements should be mailed.
Street Address _______________________________________________________________________
Apt. # ________________
City _________________________________________________________________
State ________
Zip __________________
Home Phone No. (
)
-
Please also complete corresponding sections on page 2
Worker Signature _________________________________________________
Date
/
/
By signing above, 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.
Accountholder Signature___________________________________________
(If worker doesn’t have authority to authorize deposits to the accountholder’s account.)
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DP0002 2/07
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