DP0002 10/17
Form Expires 10/31/20
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: 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 CLEARLY IN BLACK/BLUE INK ONLY
Routing/Transit
Account Number**
I wish to deposit (check one):
Checking
Savings
Specific Dollar Amount $
Checking
Savings
CHANGING EXISTING DEPOSIT AMOUNTS
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
From _____% to____% of Net
From $ ______ .00 To $_____.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.
Employer/Company Representative Printed Name: ________________________________
Employer/Company Representative Signature
:_____________________________________
Date:
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN 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 to make direct deposits into the named account.
Employee/Worker Signature ______________________________________ Date ________________
Digital or Electronic Signatures are
* 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.
_______________ .00
Type of Account:
Routing/Transit
Account Number**
I wish to deposit (check one):
Specific Dollar Amount $
_______________ .00
Type of Account:
Routing/Transit
**
I wish to change my deposit amount to (check one):
Type of Account:
Accountholder's Name:
Accountholder's Name:
Checking
Savings
Accountholder's Name:
