DIRECT DEPOSIT ENROLLMENT FORM FOR BUSINESSES & INDIVIDUALS

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Emploi et

Développement social Canada

Employment and

Social Development Canada

PROTECTED WHEN COMPLETED - B

DIRECT DEPOSIT ENROLLMENT FORM FOR BUSINESSES & INDIVIDUALS

PRIVACY NOTICE The personal information is collected under the Financial Administration Act, ss. 17(1) and 35(2). The

information is used and disclosed to relevant federal program(s) and your financial institution for direct deposit purposes. Direct

deposit payments cannot be made without provision of information requested. Personal information is protected in accordance

with the provisions of the Privacy Act. Under the Act, individuals and businesses have a right to request access and correct their

personal information, if erroneous or incomplete.

Print clearly and in block letters. Please inform the department of any changes to your banking information. Should the

department require clarification on the data you have provided, we will contact you.

PART A All Fields are Mandatory

Legal Business Name

Individual Name (surname, first name)

Address

(Include Unit No., R.R.

or P.O. Box)

Province

City, Town Postal Code

Email Address

Telephone Extension

Business Number

Social Insurance Number

PART B All Fields are Mandatory

Branch No.

Institution No.

Account No.

Financial Institution's Stamp Here

Name of Account Holder(s)

(Mandatory if no voided

cheque is enclosed with

your request)

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Signature of Authorized Representative or of individual

How to complete Part B

See example below

1. Cheque number - not required.

2. Branch number - 5 digits.

3. Institution number - 3 digits.

4. Account number - as shown on your cheque.

Instead of completing Part B, you can attach a blank cheque for your bank account with "VOID" written on it. DO NOT

ENCLOSE ANYTHING OTHER THAN YOUR VOIDED CHEQUE WITH THIS FORM.

PART C

I, as an authorized representative of this business or as the individual entitled to receive payment, grant the Receiver General

for Canada the right to deposit future payment(s) directly into the bank account specified until further notice.

Date (YYYY-MM-DD)

Preferred Language

English French

MAILING INSTRUCTIONS

Employment and Social Development Canada

CFOB Business Centre

2nd Floor Mailstop 212

140 Promenade du Portage, Phase IV

Gatineau, QC K1A 0J9