Scribd
Upload
231 views1 page

Direct Deposit Form

This document is a direct deposit signup/change form for workers to enroll or change their direct deposit information. It contains fields for the worker to provide their name, last 4 digits of their social security number, bank account information including bank name, account type (checking or savings), account number, and what percentage or amount of their pay to deposit into each account. The worker must sign to authorize their employer to deposit wages into the specified accounts. The employer section includes fields for the employer to verify the worker's bank documentation and sign to confirm the direct deposit request.

Uploaded by

Miguel Rendon
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
231 views1 page

Direct Deposit Form

This document is a direct deposit signup/change form for workers to enroll or change their direct deposit information. It contains fields for the worker to provide their name, last 4 digits of their social security number, bank account information including bank name, account type (checking or savings), account number, and what percentage or amount of their pay to deposit into each account. The worker must sign to authorize their employer to deposit wages into the specified accounts. The employer section includes fields for the employer to verify the worker's bank documentation and sign to confirm the direct deposit request.

Uploaded by

Miguel Rendon
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Direct Deposit Signup/Change Form

WORKER REQUIRED INFORMATION


PLEASE PRINT IN BLACK INK ONLY

WORKERS: Retain a copy of this form for your records. Return the original to your employer. EMPLOYERS: Return this form to your local Paychex office.

Worker Name ___________________________________ Last four digits of Social Security Number ___ ___ ___ ___

COMPLETE TO ENROLL OR CHANGE ENROLLMENT IN DIRECT DEPOSIT PLEASE PRINT IN BLACK INK ONLY Bank Account Type of Bank Name Deposit Type (check Change My Deposit Number* Account one): Amount to: Checking Savings Chase Pay Card Plus Checking Savings Chase Pay Card Plus If Chase Pay Card Plus, fill out attached application. Remainder of Net Pay _____ % of Net Specific Dollar Amount $ _______ .00 Remainder of Net Pay _____ % of Net Specific Dollar Amount $ _______ .00 Remainder of Net Pay ______ % of Net Specific Dollar Amount $ _____________ .00 Remove from Direct Deposit Remainder of Net Pay ______ % of Net Specific Dollar Amount $ _____________ .00 Remove from Direct Deposit

If Chase Pay Card Plus, fill out attached application.

Please attach one of the following for Checking or Savings accounts (check one): Voided check with name imprinted (no starter checks) Deposit slip (only accepted if the verbiage ACH R/T appears before the routing number) Bank letter or specification sheet (the signature of your local bank representative MUST be included) *Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account. WORKER CONFIRMATION STATEMENT
PLEASE PRINT IN BLACK INK ONLY

I authorize my employer to deposit my wages/salary into the bank accounts specified above. My signature below indicates that 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. Worker Signature __________________________________________ Date ______________ Accountholder Signature ____________________________________ (if workers name does not appear on bank documentation)
EMPLOYER SECTION ONLY
PLEASE PRINT IN BLACK INK ONLY

Company Name ________________________________________________________________ Service Location/Client Number ___________________________________________________ Federal ID Number (last 4 digits) ___ ___ ___ ___ 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 ________________________________________ Date ______________
Paychex Use Only Worker # ____________________ Time & Date _________________ PRS________________________ Contact _____________________ Verified By___________________ CSS ________________________ Scanning instructions are located in Paychex Procedures.

DP0002 1/11

You might also like