Direct Deposit/access Card Change Form
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Client Number ________________
Worker Number _______________
Direct Deposit/Access Card
PRS ________________________
Date________________________
Change 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 change your existing payroll information.
2.
Return this form to your local Paychex office.
3.
Sign the bottom of the form.
4.
Retain a copy of this form for your records. Return the
original to your employer.
WORKER – Required Information
EMPLOYER – Required Information
PLEASE PRINT
PLEASE PRINT
Company Name ____________________________________
Worker Name ____________________________________
Social Security Number
Office/Client Number
___ ___ ___ ___ / ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Federal ID Number
Street Address __________________________ Apt. # ______
___ ___ ___ ___ ___ ___ ___ ___ ___
City ___________________ State ______ Zip
___ ___ ___ ___ ___
Complete for DIRECT DEPOSIT
Bank Account #1
Bank Account #2
Bank Account #3
Checking
Savings
Checking
Savings
Checking
Savings
Account Number*_______________________
Account Number*_______________________
Account Number*______________________
Bank Name ___________________________
Bank Name ___________________________
Bank Name __________________________
Remove From Direct Deposit
Remove From Direct Deposit
Remove From Direct Deposit
OR
OR
OR
Change My Deposit Amount To:
Change My Deposit Amount To:
Change My Deposit Amount To:
Entire Net Pay
Entire Net Pay
Entire Net Pay
__________ % of Net
__________ % of Net
__________ % of Net
Specific Dollar Amount $ ___________.00
Specific Dollar Amount $ ___________.00
Specific Dollar Amount $ ___________.00
* If your bank account number has changed, you must provide a voided check or bank specification sheet.
Complete for ACCESS CARD
Last 8 digits appearing on card (required)
____ ____ ____ ____ ____ ____ ____ ____
1.
Change My Name
3.
Add Another Person to My Account
(a new card will be created)
PLEASE PRINT
PLEASE PRINT
Old Name ________________________________________________
Additional Cardholder Name ________________________________
New Name _______________________________________________
Additional Cardholder SS#
____ ____ ____ - ____ ____ - ____ ____ ____ ____
2.
Change My Address and/or Phone Number
4.
Change My Deposit Amount To:
PLEASE PRINT
Street Address _______________________________ Apt. # ______
Entire Net Pay
City _____________________ State _______ Zip
__________ % of Net
___ ___ ___ ___ ___
Phone
Specific Dollar Amount $ __________.00
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
5.
Close My Account
Note: All cards with the same name and social security number will be affected by this change.
Worker Signature _______________________________ Date __ __ / __ __ / __ __ Return this original form to your employer.
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.)
DP0013 12/05 BC
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Parent category: Financial