Direct Deposit Enrollment/Change Form - Paychex

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Direct Deposit Enrollment/Change Form
Company Name____________________________________ Client Number____________________
Employee/Worker Name_____________________________ Employee/Worker Number__________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer.
EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a copy of
this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of Account
Routing/Transit
Checking/Savings
Financial Institution
I wish to deposit (check one):
Number
Account Number*
(“Bank”) Name
 _____ % of Net
 Checking
 Specific Dollar Amount $
 Savings
_______________.00
 Remainder of Net Pay
 _____ % of Net
 Specific Dollar Amount $
 Checking
_____________________________
 Savings
.00
 Remainder of Net Pay
COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Routing/Transit
Checking/Savings
Financial Institution
Change My Deposit Amount to:
Number
Account Number*
(“Bank”) Name
 From _____% to____% of Net
 From $ ______ .00 To $_____.00
 Remainder of Net Pay
 From _____% to____% of Net
 From $ ______ .00 To $_____.00
 Remainder of Net Pay
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above and, if necessary, to electronically debit
my account to correct erroneous credits. I certify my account(s) allow these transactions. I agree that direct deposit transactions I
authorize comply with all applicable laws. 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
Employee/Worker Signature ______________________________________ Date ________________
Note:
Digital or Electronic Signatures are not acceptable.
One of the following is required to process this enrollment (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)
Other Bank Documentation from your Financial Institution – If this box is checked the employer must sign this
confirmation:
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions
processed by Paychex, Inc.
Employer Printed Name
:________________________________
Employer Signature
:_____________________________________
Date _______________
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to
your account.
DP0002 7/16
Form Expires 7/30/19
Direct Deposit Enrollment/Change Form
Company Name____________________________________ Client Number____________________
Employee/Worker Name_____________________________ Employee/Worker Number__________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer.
EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a copy of
this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of Account
Routing/Transit
Checking/Savings
Financial Institution
I wish to deposit (check one):
Number
Account Number*
(“Bank”) Name
 _____ % of Net
 Checking
 Specific Dollar Amount $
 Savings
_______________.00
 Remainder of Net Pay
 _____ % of Net
 Specific Dollar Amount $
 Checking
_____________________________
 Savings
.00
 Remainder of Net Pay
COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Routing/Transit
Checking/Savings
Financial Institution
Change My Deposit Amount to:
Number
Account Number*
(“Bank”) Name
 From _____% to____% of Net
 From $ ______ .00 To $_____.00
 Remainder of Net Pay
 From _____% to____% of Net
 From $ ______ .00 To $_____.00
 Remainder of Net Pay
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above and, if necessary, to electronically debit
my account to correct erroneous credits. I certify my account(s) allow these transactions. I agree that direct deposit transactions I
authorize comply with all applicable laws. 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
Employee/Worker Signature ______________________________________ Date ________________
Note:
Digital or Electronic Signatures are not acceptable.
One of the following is required to process this enrollment (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)
Other Bank Documentation from your Financial Institution – If this box is checked the employer must sign this
confirmation:
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions
processed by Paychex, Inc.
Employer Printed Name
:________________________________
Employer Signature
:_____________________________________
Date _______________
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to
your account.
DP0002 7/16
Form Expires 7/30/19

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