Direct Deposit/access Card Employee Signup Form
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1Direct Deposit/Access Card
PAYCHEX
®
Employee Signup Form
Employee Instructions:
EMPLOYEE - Required Information
1. Complete the employee required information section.
PLEASE PRINT
2. Complete the Direct Deposit, Access Card, or both
Employee Name
sections to specify where you want your pay deposited.
Social Security No.
/
/
3. Sign the bottom of the form.
4. Retain a copy of this form. Return the original to
your employer.
Employer Instructions:
EMPLOYER - Required Information
1. Complete the employer required information section.
PLEASE PRINT
Client Name
2. Return this form to your local Paychex office.
Office/Client No.
/
Federal ID No.
Complete for DIRECT DEPOSIT
I would like my wages/salary deposited to the following bank account(s):
❑
❑
❑
❑
Bank Account #2
Checking
Savings
Bank Account #1
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
Voided check
❑
❑
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 $3.00 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
❑
❑ Specific Dollar Amount $
% of Net
.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.
#152221 Rev. 9/03 CT
DP0002
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Parent category: Financial