Fillable Printable Direct Deposit Enrollment or Change Form

Direct Deposit Enrollment or Change Form

Direct Depos it Enrollment/Cha nge 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

Number

Checking/Savings

Account Number*

Financial Institut ion

(“Bank ”) Name

I wish to deposit (check one):



Checking



Savings



_____ % of Net

 Specific Dollar Amount $ _______ .00

 Remainder of Net Pay



Checking



Savings



_____ % of Net

 Specific Dollar Amount $ _______ .00

 Remainder of Net Pay

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 inc luded)

 Other Bank Documentation from your Financial Institution – If this box is checked the em ployer 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 Signat ur e:_____________________________________ Date _______________

*Certain accounts may have restrictions on de posits and withdrawals. Check with your bank for more i nfor mation

specific to your account.

COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLE ASE PRINT IN BLACK/BLUE INK ONLY

Routing/Tra nsit Number

Checking/Savings

Ac count Number*

Financial Institution

(“Bank”) Name

Change My Deposit Amount to:

 From _____% to____% of N et

 From $ ______ .00 To

$_____.00



Remainder of Net Pay

 From _____% to____% of N et

 From $ ______ .00 To

$_____.00



Remainder of Net Pay

EMPLOYEE/WORKER CONFIRMATION STATEM E NT

PLEASE SIGN IN BLACK/BLUE INK ON LY

I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct depos i t transactions

I authorize com ply w ith all appl icab le law . My signature below indicates that I am agreeing that I am either the accountholder or

have the authority of the accountholder to authorize my em ployer to make direct deposits into the named account.

Employee/Worker Signature _______________________________________ Date ________________

Note: Digital or Electronic Signatures are not acceptable.

DP0002 12/14