Direct Deposit Signup/change Form

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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
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
Bank Account
Type of
Bank Name
Deposit Type (check
Change My Deposit
Number*
Account
one):
Amount to:
 Checking
 Remainder of Net
 Remainder of Net
 Savings
Pay
Pay
 ______% of Net
 _____ % of Net
 Chase Pay
If Chase Pay Card Plus, fill out
 Specific Dollar
 Specific Dollar
Card Plus
attached application.
Amount $ ______ .00
Amount $ ______ .00
 Remove from Direct
Deposit
 Checking
 Remainder of Net
 Remainder of Net
 Savings
Pay
Pay
 ______% of Net
 _____ % of Net
 Chase Pay
If Chase Pay Card Plus, fill out
 Specific Dollar
 Specific Dollar
Card Plus
attached application.
Amount $ ______ .00
Amount $ ______ .00
 Remove from Direct
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
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 my employer 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
Company Name ________________________________________________________________
Service Location/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, Inc.
Employer Signature ________________________________________ Date ______________
Paychex Use Only
Worker # ____________________ Time & Date _________________
PRS________________________ Contact _____________________
Verified By___________________ CSS ________________________
DP0002 11/10
Scanning instructions are located in Paychex Procedures.

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