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Direct Deposit

Direct Deposit

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Published by tbell_4boys!

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Published by: tbell_4boys! on Mar 15, 2010
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07/28/2010

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Page 1 of 2 DP0002 2/08
Direct Deposit/Access CardSignup Form
Worker Instructions:
1.
Complete the “WORKER - Required Information” section.
2.
Complete the Direct Deposit, Access Card, or bothsections to specify where you want your pay deposited.
3.
Sign the bottom of the form.
4.
Retain a copy of this form for your records. Return theoriginal to your employer.
WORKER Required Information
PLEASE PRINT 
Worker Name ____________________________________ Last four digits of Social Security Number
___ ___ ___ ___ 
 
Employer Instructions:
 
1.
Complete the “EMPLOYER - Required Information”section.
2.
Return this form to your local Paychex office.**
See below for acceptable bank account documentation.
Depositslips are not accepted.
EMPLOYER Required Information
PLEASE PRINT 
Company Name ____________________________________ Office/Client Number ________________________________ Federal ID Number
 ___ ___ ___ ___ ___ ___ ___ ___ ___ 
 
Complete for DIRECT DEPOSIT and Sign Below
I authorize my employer to deposit my wages/salary to the following bank account(s):Bank Account #1
Checking
Savings
 
Bank Account #2
Checking
Savings
 
Bank Name_________________________________ Bank Name_________________________________ I wish to deposit (check one): I wish to deposit (check one):
Remainder of Net Pay
Remainder of Net Pay
______ % of Net
______ % of Net
Specific Dollar Amount $ ______.00
Specific Dollar Amount $ ______.00Please attach one of the following (check one): Please attach one of the following (check one):
Voided check (deposit slips are not accepted)
 
Voided check
 
(deposit slips are not accepted)
 
Bank letter or specification sheet*
 
Bank letter or specification sheet*
 
*See your local bank representative. *See your local bank representative.
Complete for ACCESS CARD and Sign Below
 
I authorize my employer to deposit my wages/salary to an Access Card account.
I agree to the terms and conditions of thePaychex Access Card Program including the
$2.00
monthly maintenance fee, the
$1.50
per ATM withdrawal fee, the
$3.00
over-the-counter cash advance fee, and the
$15.00
lost or stolen card replacement fee.
I wish to deposit (check one):
Remainder of Net Pay
___________% of Net
Specific Dollar Amount $ __________.00
 Please print
the address where the Access Card statements should be mailed.Street Address_______________________________________________________________________ Apt. #_______________City_________________________________________________________________ State________ Zip__________________ Home Phone No. ( ) -
Please also complete corresponding sections on page 2
Worker Signature
 _________________________________________________ 
Date
/
By signing above, I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make directdeposits into the named account.
Accountholder Signature___________________________________________ 
(If worker doesn’t have authority to authorize deposits to the accountholder’s account.)
Paychex Use Only
Client Number________________ Worker Number_______________ PRS________________________ Date________________________ Verified By___________________ 

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