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

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

 Savings

Pay

 ______% of Net

 _____ % of Net

 Chase Pay

If Chase Pay Card Plus, fill out

 Specific Dollar

Card Plus

attached application.

Amount $ ______ .00

 Remove from Direct

Deposit

 Checking

 Remainder of Net

 Savings

Pay

 ______% of Net

 _____ % of Net

 Chase Pay

If Chase Pay Card Plus, fill out

 Specific Dollar

Card Plus

attached application.

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.

Direct Deposit Signup/change Form

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