Direct Deposit Signup Form
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1Paychex Use Only
Client Number
Date
Worker Number
Time
PRS
Contact
Verified By
CSS Initials
Scanning instructions are located in Paychex Procedures,
_
_
_
_
Worker Instructions:
1.
Complete the "WORKER - Required Information" section.
2.
Complete the Direct Deposit section to specify where you
want your pay deposited.
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
PLEASE PRINT
Worker Name
- - - - -
Last four digits of Social Security Number
_
PAYCHEX~
Direct Deposit Signup Form
Employer Instructions:
1. Complete the "EMPLOYER· Required Information"
section.
2.
Return this form to your local Paychex office:
·See below for acceptable ba'nk documentation.
EMPLOYER - Required Information
PLEASE PRINT
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Company Name
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USA)
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Service Location/Client Number
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Federal
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Number
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Complete for Direct Deposit and Sign Below
I authorize my employer to deposit my wages/salary to the foHowing bank account(s):
Bank Account #1
o
Checking
Bank Name
_
o
Savings
Bank Name
_
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I wish to deposit (check one):
D
Remainder of Net Pay
D
%
of Net
D
Specific Dollar Amount $
.00
Please attach one of the following for Checking or
Savings accounts (check one):
o
Voided check with name imprinted (no starter
checks)
o
Deposit slip (only accepted if the verbiage "ACH
RIT" appears before the routing number)
o
Bank letter or specification sheet (the signature of
your local bank representative MUST be included)
Bank Account #2
o
Checking
Bank Name
_
o
Savings
Bank Name
_
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I wish to deposit (check one):
D
Remainder of Net Pay
D
%
of l\Jet
D
Specific Dollar Amount.$
.00
Please attach one of the following for Checking or
Savings accounts (check one):
o
Voided check with name imprinted (no starter
checks)
o
Deposit slip (.Q!!!y accepted if the verbiage "ACH
RIT"
appears before the routing number)
o
Bank letter or specification sheet (the signature of
your local bank representative MUST be included)
Employer Section Only
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
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 Sig nature _ _---:-----:-----:-
--:---:-
_
(if worker's name does not appear on bank
docu~entation)
DP0002 12/09
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