Direct Deposit/access Card Employee Signup Form
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1Paychex Use Only
Client Number ________________
Employee Number ____________
Direct Deposit/Access Card
PRS ________________________
Date________________________
Employee Signup Form
Verified By___________________
Employee Instructions:
Employer Instructions:
1.
Complete the “Employee Required Information” section.
1.
Complete the “Employer Required Information” section.
2.
Complete the Direct Deposit, Access Card, or both
2.
Return this form to your local Paychex office.
sections to specify where you want your pay deposited.
3.
Sign the bottom of the form.
4.
Retain a copy of this form. Return the original to your
employer.
EMPLOYEE – Required Information
EMPLOYER – Required Information
PLEASE PRINT
PLEASE PRINT
Employee Name ____________________________________
Company Name ____________________________________
Social Security Number
Office/Client Number
___ ___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ ___ ___ / ___ ___ ___ ___
Federal ID Number
___ ___ ___ ___ ___ ___ ___ ___ ___
Complete for DIRECT DEPOSIT
I would like my wages/salary deposited 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
I would like my wages/salary deposited to an Access Card account. I agree to the terms and conditions of the Paychex Access
Card Program including the $2.00 monthly maintenance fee, the $1.50 per ATM withdrawal fee, the $3.00 over-the-
counter cash advance fee, and the $15.00 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. (
)
-
Date of Birth
/
/
Mother’s Maiden Name _____________________________________________________
Additional Card Requested.
Additional Card Holder Name_________________________________________________
Additional Card Holder Social Security No.
/
/
Employee Signature _______________________________________________
Date
/
/
Return this original form to your employer.
DP0002 3/05
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Parent category: Financial