Direct Deposit Signup Form
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1Paychex Use Only
Client Number ________________
Worker Number _______________
Direct Deposit Signup Form
PRS ________________________
Date________________________
Verified By___________________
Scanning instructions are located
in Paychex Procedures.
Worker Instructions:
Employer Instructions:
1. Complete the “WORKER - Required Information”
1. Complete the “EMPLOYER - Required Information”
section.
section.
2. Complete the Direct Deposit section to specify
2. Return this form to your local Paychex office.*
*See below for acceptable bank documentation. Deposit slips
where you want your pay deposited.
are not accepted.
3. Sign the bottom of the form.
4. Retain a copy of this form for your records. Return
the original to your employer.
EMPLOYER – Required Information
WORKER – Required Information
PLEASE PRINT
PLEASE PRINT
Company Name
__________________________________
Worker Name _________________________________
Office/Client Number
__________________________________
Last four digits of Social Security 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
Bank Account #2
Checking
Checking
Bank Name _______________________________
Bank Name _______________________________
Savings
Savings
Bank Name _______________________________
Bank Name _______________________________
Chase Pay Card Plus
Chase Pay Card Plus
Please complete the attached application if you would
Please complete the attached application if you would
like to sign up for Chase Pay Card Plus.
like to sign up for Chase Pay Card Plus.
I wish to deposit (check one):
I wish to deposit (check one):
Remainder of Net Pay
Remainder of Net Pay
________ % of Net
_________ % of Net
Specific Dollar Amount $___________ .00
Specific Dollar Amount $ ___________ .00
Please attach one of the following for Checking or
Please attach one of the following for Checking or
Savings accounts (check one):
Savings accounts (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
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.)
DP0002 4/08
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