New Employee Set Up Forms Other States

PayData Employee Set up Form:
Company # _______
Company Name:
Date: _______________
Employee # __________
New Hire _____ Rehire _____ Employee changes ______
*Employee Full Name
*Mailing Address
*City, State, Zip
Employee Email Address
Date of Birth: ________________ *Date of Hire: _____________
*Gender: M or F
Termination Date: ____________________
Salary Y or N
Per Pay Salary Amount $____________________ Div/Branch/ Dept: __________________________
Rate of Pay: __________
Override Div/Branch/ Dept __________________________ Full or Part time
Rate of Pay: __________
Override Div/Branch/ Dept: __________________________
*Federal Withholding: M or S
*Withholding State:
# of Exemptions
Add Fed $ ____________
Work Visa: N o r YES # ______________________
Override State Withholding: (Specify State) _____ M or S # of Exemptions
Add SWT $_________
* VT Employee Health Insurance Coverage Status:____ Not Covered _____Covered by Company Plan ____Covered by Spouse Plan_____Other
Time Off Banks
Begin Balances
Deduction Name
Direct Deposit Information:
Bank Name
Per Pay Amount
Account Type
(C or S or HSA)
Per Pay Percentage
Bank ABA#
Account #
Amount or
Full NET
I (we) hereby authorize and request the COMPANY, to make payment of any amounts owing to me (either of us) by initiating credit entries to my (our) account
indicated above in the bank named above, hereinafter called BANK, and I (we) authorize and request BANK to accept any credit entries initiated by COMPANY to
such account and to credit the same to such account without responsibility for the correctness thereof.
I (we) authorize and request COMPANY to effect repayment to COMPANY for amounts owed it because of a prior erroneous credit initiated to my (our) account if
prior to the correcting entry, the COMPANY has sent or delivered to me written notice of the correction and the reason therefore; and the correcting entry is
transmitted in such time as to be delivered or made available to BANK before midnight of the tenth day next following settlement for the erroneous entry.
It is understood that this agreement may be terminated by me (either of us) at any time by written notification to COMPANY or BANK. Any such notification to
COMPANY shall be effective only with respect to entries initiated by COMPANY after receipt of such notification and a reasonable opportunity to act on it. Any
such notification to BANK shall be effective only with respect to entries credited to my (our) account by BANK after receipt of such notification and a reasonable
time to act on it.
I (we) recognize, acknowledge and accept this service is being provided for my (our) convenience. As such, I (we) agree to hold the COMPANY, PayData Payroll
Services, Inc., each participating bank and NACHA harmless from any claim incident to the operation of this plan, arising from any act or omission by the
COMPANY and/or PayData Payroll Services, Inc. and their employees, including without limitation any claim based on alleged loss as a result of non-credit of any
deposit, and any claim which may be made by any depositor as a result of the rejection of any of his/her debits because of insufficient funds arising from the failure
to credit deposits to his/her account.
PRE-NOTE: PayData highly encourages that all account go through the pre-noting process. The ONLY times when you should say Pre-note NO is if you are
setting up a Direct Deposit account that will be used with an HSA
Employee Signature: ______________________________________________________________
Submitted by: ____________________________________________________________________