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DP0002 5/07
Direct Deposit/Access Card
Signup Form
Worker Instructions:
1. Complete the “WORKER - Required Information” section.
2. Complete the Direct Deposit, Access Card, or both
sections 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 the
original 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. Deposit
slips 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):
Entire Net Pay
Entire Net Pay
______ % of Net
______ % of Net
Specific Dollar Amount $ ______ .00
Specific Dollar Amount $ ______ .00
Please 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 the
Paychex Access Card Program