Paychex Direct Deposit 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: Please retain a copy of this document fo r your records.

Type of Account 1

Checking

Savings

Account holder's Name:

Routing/Transit Number

Checking/Savings Account Number**

Financial Institution (“Bank”) Name

Account 1 - I wish to deposit (check one):

% of Net

Specific Dollar Amount

Remainder of Net Pay

% or $ Amount

Type of Account 2

Checking

Savings

Account holder's Name:

Routing/Transit Number

Checking/Savings Account Number**

Financial Institution (“Bank”) Name

Account 2 - I wish to deposit (check one):

% of Net

Specific Dollar Amount

Remainder of Net Pay

% or $ Amount

Type of Account 3

Checking

Savings

Account holder's Name:

Routing/Transit Number

Checking/Savings Account Number**

Financial Institution (“Bank”) Name

Account 3 - I wish to deposit (check one):

% of Net

Specific Dollar Amount

Remainder of Net Pay

% or $ Amount

I agree to add/update my tax information in our payroll system(Required)
Yes

Employee/Worker Signature

Date
MM slash DD slash YYYY