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

Checking

Savings

Checking

Savings

Routing/Transit
Number

Checking/Savings
Account Number*

Financial Institution
(“Bank”) Name

I wish to deposit (check one):
 _____ % of Net
 Specific Dollar Amount $ _______ .00
 Remainder of Net Pay
 _____ % 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 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 Signature:_____________________________________ Date _______________
*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.
COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY
Routing/Transit Number

Checking/Savings
Account Number*

Financial Institution
(“Bank”) Name

Change My Deposit Amount to:
 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. I agree that direct deposit transactions
I authorize comply with all applicable 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 employer to make direct deposits into the named account.
Employee/Worker Signature _______________________________________ Date ________________

Note:

Digital or Electronic Signatures are not acceptable.

DP0002 12/14
Form Expires 12/31/17