Direct Deposit Signup/Change Form - Please Print in Black Ink Only

Sep 22, 2026

Direct Deposit Signup/Change Form for workers and employers to enroll or update direct deposit details processed by Paychex. The form collects worker identification, bank account information, account type, financial institution name, and deposit allocation options including checking, savings, remainder of net pay, percentage, specific dollar amounts, or removal from direct deposit. It requires attachment of valid verification for checking or savings, a worker authorization signature and date, and an employer confirmation signature and date, with Paychex internal use fields for processing and verification.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

WORKER – REQUIRED INFORMATION

Complete to Enroll or Change Enrollment in Direct Deposit

Worker Confirmation Statement

EMPLOYER SECTION ONLY

Direct Deposit Signup/Change Form | WORKER – REQUIRED INFORMATION | | --- | | PLEASE PRINT IN BLACK INK ONLY
Worker Name Last four digits of Social Security Number | Please complete all sections of this form. WORKERS: 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 Preview Payroll Clients, retain on file after updating the employee record. | COMPLETE TO ENROLL OR CHANGE ENROLLMENT IN DIRECT DEPOSIT – PLEASE PRINT IN BLACK INK ONLY | | | | | | --- | --- | --- | --- | --- | | Bank Account Number* | Type of Account | Financial Institution
(“Bank”) Name | Deposit Type (check one): | Change My Deposit Amount to: | | | 􀂆 Checking
􀂆 Savings | | 􀂆 Remainder of Net Pay
􀂆 % of Net
􀂆 Specific Dollar Amount $ .00 | 􀂆 Remainder of Net Pay
􀂆 % of Net
􀂆 Specific Dollar Amount $ .00
􀂆 Remove from Direct Deposit | | | 􀂆 Chase Pay Card Plus | If Chase Pay Card Plus, fill out attached application. | | | | | 􀂆 Checking
􀂆 Savings | | 􀂆 Remainder of Net Pay
􀂆 % of Net
􀂆 Specific Dollar Amount $ .00 | 􀂆 Remainder of Net Pay
􀂆 % of Net
􀂆 Specific Dollar Amount $ .00
􀂆 Remove from Direct Deposit | | | 􀂆 Chase Pay Card Plus | If Chase Pay Card Plus, fill out attached application. | | | Please attach one of the following for Checking or Savings accounts (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) *Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account. | | WORKER CONFIRMATION STATEMENT | | --- | --- | | | PLEASE PRINT IN BLACK INK ONLY
I authorize my employer to deposit my wages/salary into the bank accounts specified above. 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.
Worker Signature Date Accountholder Signature
(if worker’s name does not appear on bank documentation) | | | EMPLOYER SECTION ONLY | | --- | --- | | | PLEASE PRINT IN BLACK INK ONLY
Company Name Service Location/Client Number Federal ID Number (last 4 digits)
If bank documentation provided is different from what is listed above, the following must be completed by the employer:
I confirm that the above named employee has added or changed a bank account for direct deposit transactions processed by Paychex, Inc.
Employer Signature Date
Massachusetts Library System | Paychex Use Only Worker \# Time & Date PRS Contact Verified By CSS Scanning instructions are located in Paychex Procedures. DP0002 3/12 CHOOSE A BETTER WAY TO GET PAID Instead of waiting in line to cash your paycheck, have your pay automatically deposited to a Chase Pay Card Plus account. It’s safe, fast and [easy...plus](easy...plus) it saves you money! Get cash 24 x 7 at ATMs worldwide Make purchases anywhere Visa® debit cards are accepted Shop online, by phone or mail order Pay your bills online Eliminate the hassle and costs of cashing a check No lost or stolen checks No credit check required Receive payroll deposits from multiple employers Get your money anywhere, anytime With the Chase Pay Card Plus program, your funds are electronically deposited to your Chase Pay Card Account each pay period, where your funds are FDIC insured. You then have immediate and convenient access to your money at over 900,000 automated teller machines (ATMs). You can enjoy surcharge-free access at over 51,000 Chase and Allpoint® ATMs in the U.S., and at millions of locations that accept Visa debit cards. Your pur

FAQs

What information must workers provide on the Direct Deposit form?

Workers must provide their name and the required worker details, then complete the bank account number and deposit selection fields. The form also requires a worker signature and date.

What options are available to change direct deposit enrollment?

Deposit type choices include checking or savings, with options to allocate the remainder of net pay, a percentage of net pay, a specific dollar amount, or remove the employee from direct deposit.

What does the employer section require?

The employer must confirm that the employee added or changed a bank account for Paychex direct deposit transactions, and provide the company name, service location/client number, federal ID (last 4 digits), employer signature, and date.

Sep 22, 2026

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