Direct Deposit Enrollment/Change Form*
Company Name and/or 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/company.
Employer/Company: Please retain a copy of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by
Paychex, Inc. I have reviewed the information provided and it is accurate to the best of my knowledge. My signature below indicates that
I have the authority to execute this document on behalf of the Client.
CONFIRMATION STATEMENT
Digital or Electronic Signatures are not acceptable.
* All fields are required except Employee/Worker Number.
** Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.
Checking/Savings Account Number**
Type of Account
Checking
Savings
Account holder's Name:
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
Financial Institution (“Bank”) Name
Routing/Transit Number
Type of Account
Checking
Savings
Account holder's Name:
Add new Replace existing account Last 4 digits of the existing account number
MM/DD/YY
Employer/Company Representative Printed Name: _______________________________
Employer/Company Representative Signature: _____________________________________ Date: ______________
Financial Institution (“Bank”) Name
Checking/Savings Account Number**
Add new Replace existing account Last 4 digits of the existing account number
Type of Account
Checking
Savings
Routing/Transit Number
Checking/Savings Account Number**
Add new Replace existing account Last 4 digits of the existing account number
Account holder's Name:
Routing/Transit Number
Financial Institution (“Bank”) Name
DP0002 10/20
Form Expires 10/31/23
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
I authorize my employer/company to deposit my earnings into the bank account(s) specified above and, if necessary, to electronically
debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore, I certify that the above listed
account number accurately reflects my intended receiving account. 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/company make direct deposits into the named account. I understand that this authorization will
remain in full force and effect until I notify Company in writing that I wish to revoke my authorization.I understand that the Company
requires at least 5 business days prior notice to cancel this authorization.
Employee/Worker Signature
________________________________________
________________
Date:
