Direct Deposit Form

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(Print Legible First and Last Name)

Type of Account

Type of Account

Type of Account

I authorize my employer/company to deposit my earnings into the bank account(s) specified above, and, if necessary, to electronically debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore, I certify that the above listed account number accurately reflects my intended receiving account. I agree that direct deposit transactions I authorize comply with all applicable laws. 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/company make direct deposits into the named account. I understand that this authorization will remain in full force and effect until I notify Company in writing that I wish to revoke my authorization. I understand that the Company requires at least 5 business days prior notice to cancel this authorization.

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MM slash DD slash YYYY

I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by Paychex, Inc. I have reviewed the information provided and it is accurate to the best of my knowledge. My signature below indicates that I have the authority to execute this document on behalf of the client.

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MM slash DD slash YYYY

FOR DISPLAY ONLY

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