Direct Deposit Form

Direct Deposit Signup/Change Form
Please complete all sections of this form. WORKER REQUIRED INFORMATION

PLEASE PRINT IN BLACK INK ONLY
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.
Worker Name ___________________________________ Last four digits of Social Security Number ___ ___ ___ ___
COMPLETE TO ENROLL OR CHANGE ENROLLMENT IN DIRECT DEPOSIT PLEASE PRINT IN BLACK INK ONLY Bank Account Type of Financial Institution Deposit Type (check Change My Deposit Number* Account (Bank) Name one): Amount to: Checking Savings Chase Pay Card Plus Checking Savings Chase Pay Card Plus If Chase Pay Card Plus, fill out attached application. Remainder of Net Pay _____ % of Net Specific Dollar Amount $ _______ .00 Remainder of Net Pay _____ % of Net Specific Dollar Amount $ _______ .00 Remainder of Net Pay ______ % of Net Specific Dollar Amount $ _____________ .00 Remove from Direct Deposit Remainder of Net Pay ______ % of Net Specific Dollar Amount $ _____________ .00 Remove from Direct Deposit
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
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 workers name does not appear on bank documentation)
EMPLOYER SECTION ONLY
RICEFW TECHNOLOGIES INC Company Name ________________________________________________________________
11016481 Service Location/Client Number ___________________________________________________

7612 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 ______________
Paychex Use Only Worker # ____________________ Time & Date _________________ PRS________________________ Contact _____________________ Verified By___________________ CSS ________________________ Scanning instructions are located in Paychex Procedures.
DP0002 3/12
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. Its safe, fast and 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
CHOOSE A
Enroll in the Chase Pay Card Plus program today!

There is no cost to enroll in the Chase Pay Card Plus program. Simply complete this application today and return it to your payroll department.
Chase Payroll Card Fee Schedule

TRANSACTION ATM withdrawal (U.S.)3 ATM withdrawal (outside U.S.) Point-of-Sale transactions: PIN and Signature-based Over-the-counter cash withdrawals ATM balance inquiry (U.S.) ATM balance inquiry (outside U.S.) ADDITIONAL SERVICES Monthly paper statement (optional) Monthly statements via Internet Replace lost/stolen card $1.00 FREE $15.00 per card $25.00 includes card $1.00 per transaction $10 per request $12.00 per account $3.00 per month 3.5% per international transaction
3
CARDHOLDER FEE $1.50 per transaction $3.00 per withdrawal FREE 5 free per month, then $5.00 thereafter $1.00 per inquiry $3.00 per transaction
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 purchases are protected

For the first 90 days from the purchase date, Visas Purchase Security1 will repair or fully reimburse you for eligible items paid entirely with your Chase Pay Card to a maximum of $500 per consumer product and $50,000 per cardholder. Additionally, Visas Zero Liability Policy2 protects you from unauthorized purchases. If your Card is ever lost or stolen, you are automatically protected without losing the funds in your Account.
Expedited card delivery Declined transactions (U.S.)4 Copy of Statement Check to close account Inactivity fee (after 90 days of inactivity) Foreign exchange conversion rate
This protection is valid in cases of theft or damage due to fire, vandalism, accidentally discharged water or weather. Certain restrictions and limitations may apply. U.S.-issued cards only. The Visa Zero Liability Policy does not apply to commercial card or ATM transactions, or to PIN transactions not processed by Visa or Interlink. See your cardholder agreement for more details.
Cardholder fees apply to both the primary and secondary cardholders.

3
Chase Pay Cards are issued by JPMorgan Chase Bank, N.A. 2011 JPMorgan Chase & Co. All rights reserved. JPMorgan Chase Bank, N.A. Member FDIC.
Whenever you use any ATM there is a network or ATM withdrawal fee. Additionally non-Chase banks may charge you a surcharge typically between $1.00 and $3.00 for using their ATM. You can avoid a surcharge by using a Chase ATM or Allpoint ATM.
BRC11637
Chase Pay Card Plus Application Unless otherwise noted, all fields are required and must be filled in to process this application. You must be a U.S. Resident to enroll in the Chase Pay Card Plus program.
Federal law requires all financial institutions to obtain, verify and record information that identifies each person who applies for a card. What this means for you: when you apply for a card, you will be asked for your name, address, date of birth, and other information or documentation that will allow us to identify you.
I. CARDHOLDER INFORMATION
I. SECONDARY CARD (OPTIONAL)
LEGAL FIRST NAME
MI
LAST NAME
LEGAL FIRST NAME
MI
LAST NAME
PERMANENT ADDRESS (NO P.O. BOXES)
PERMANENT ADDRESS (NO P.O. BOXES)
CITY
STATE
ZIP
CITY
STATE
ZIP
CARD MAILING ADDRESS (IF DIFFERENT FROM PERMANENT)
PRIMARY PHONE NUMBER
CITY
STATE
ZIP
E-MAIL ADDRESS (OPTIONAL)
PRIMARY PHONE NUMBER
DATE OF BIRTH (MM/DD/YYYY)
E-MAIL ADDRESS (OPTIONAL)
SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER
MOTHERS MAIDEN NAME
DATE OF BIRTH (MM/DD/YYYY)
SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER
MOTHERS MAIDEN NAME
UNITED STATES CITIZEN NON-UNITED STATES CITIZEN If you are not a U.S. Citizen, please provide one or more of the following forms of identification. Please select a form of identification:
U.S. ALIEN ID CARD PASSPORT
UNITED STATES CITIZEN NON-UNITED STATES CITIZEN If you are not a U.S. Citizen, please provide one or more of the following forms of identification. Please select a form of identification:
U.S. ALIEN ID CARD PASSPORT
OTHER GOVERNMENT ISSUED ID TYPE
COUNTRY OF ISSUANCE EXPIRATION DATE (MM/DD/YYYY)
NUMBER
OTHER GOVERNMENT ISSUED ID TYPE
* Contact your employer for an additional secondary cardholder form.

COUNTRY OF ISSUANCE EXPIRATION DATE (MM/DD/YYYY) NUMBER
Monthly paper statement (optional) in addition to accessing my Chase Pay Card Plus transaction activity online or via Customer Support, please mail me a monthly Pay Card activity statement to the mailing address I have provided above. I understand there is a $1.00 monthly charge for this statement option.
II. CARDHOLDER AGREEMENT Return your completed, signed and dated application to your employer. The Authorization Agreement for the Chase Pay Card Plus account will authorize my employer to directly deposit my periodic salary/compensation payments, net of required tax withholdings, other required withholdings or authorized deductions (a Payroll Payment) into my Chase Pay Card Plus account (the Account) at JPMorgan Chase Bank, N.A. (Chase) and to initiate (if necessary) debit entries and adjustments for any credit entries in error to my Account. I understand that I may withdraw a portion or the entire amount of a Payroll Payment deposited by my employer from time to time in cash via an Automated Teller Machine (subject to certain withdrawal limits as discussed in the Program Terms, Conditions and Disclosures), applicable Point-of-Sale (POS) terminals and wherever Visa debit cards are accepted. By signing this application, I hereby authorize Chase to issue a card to me. I agree that activating my card shall constitute my agreement to: (1) The Program Terms, Conditions and Disclosures that accompany my card and (2) changes to, or replacements for, those Program Terms, Conditions or Disclosures that may be sent or made available to me from time to time. I also hereby authorize Chase to debit my Chase Pay Card Plus account, without notifying me, for the fees described in the fee schedule that is part of this application, or as such fees may change from time to time. Chase may change those fees at any time.
CARDHOLDERS SIGNATURE
DATE
III. BRANCH USE ONLY

COMPANY NAME CLIENT ACCOUNT NUMBER

Direct Deposit Form

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Direct Deposit Form

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What information is required to enroll in direct deposit?

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What authorization does signing the form provide?

Direct Deposit Signup/Change Form

Please complete all sections of this form. WORKER REQUIRED INFORMATION

If Chase Pay Card Plus, fill out attached application.

RICEFW TECHNOLOGIES INC Company Name ________________________________________________________________

11016481 Service Location/Client Number ___________________________________________________

Enroll in the Chase Pay Card Plus program today!

Chase Payroll Card Fee Schedule

Get your money anywhere, anytime

Your purchases are protected

Cardholder fees apply to both the primary and secondary cardholders.

I. SECONDARY CARD (OPTIONAL)

LEGAL FIRST NAME

LEGAL FIRST NAME

PERMANENT ADDRESS (NO P.O. BOXES)

PERMANENT ADDRESS (NO P.O. BOXES)

CARD MAILING ADDRESS (IF DIFFERENT FROM PERMANENT)

PRIMARY PHONE NUMBER

E-MAIL ADDRESS (OPTIONAL)

PRIMARY PHONE NUMBER

DATE OF BIRTH (MM/DD/YYYY)

E-MAIL ADDRESS (OPTIONAL)

SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER

MOTHERS MAIDEN NAME

DATE OF BIRTH (MM/DD/YYYY)

SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER

MOTHERS MAIDEN NAME

OTHER GOVERNMENT ISSUED ID TYPE

COUNTRY OF ISSUANCE EXPIRATION DATE (MM/DD/YYYY)

OTHER GOVERNMENT ISSUED ID TYPE

* Contact your employer for an additional secondary cardholder form.

III. BRANCH USE ONLY

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