HTML Preview Direct Deposit Change Form page number 1.
DP0002 11/10
Direct Deposit Signup/Change Form
WORKER – REQUIRED INFORMATION
PLEASE PRINT
Worker Name ___________________________________
Last four digits of Social Security Number ___ ___ ___ ___
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.
COMPLETE TO ENROLL OR CHANGE ENROLLMENT IN DIRECT DEPOSIT
Bank Account
Number*
Type of
Account
Bank Name Deposit Type (check
one):
Change My Deposit
Amount to:
Checking
Savings
Remainder of Net
Pay
______% of Net
Specific Dollar
Amount $ ______ .00
Remainder of Net
Pay
_____ % of Net
Specific Dollar
Amount $ ______ .00
Remove from Direct
Deposit
Chase Pay
Card Plus
If Chase Pay Card Plus, fill out
attached application.
Checking
Savings
Remainder of Net
Pay
______% of Net
Specific Dollar
Amount $ ______ .00
Remainder of Net
Pay
_____ % of Net
Specific Dollar
Amount $ ______ .00
Remove from Direct
Deposit
Chase Pay
Card Plus
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
Bank letter or specification sheet (the signature of your local bank representative MUST be included)
accepted if the verbiage “ACH R/T” appears before the routing number)
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more
information specific to your account.
WORKER CONFIRMATION STATEMENT
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 worker’s name does not appear on bank documentation)
EMPLOYER SECTION ONLY
PLEASE PRINT
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.