4179 ATT03 - Grants & Contributions Direct Deposit Request FormService
Canada
Action Requested
Direct Deposit Registration / Renewal
Changes to Direct Deposit Information
Cancellation of Direct Deposit
General Information
Organization Legal Name
Grants and Contributions
Direct Deposit Request Form
Contact Person
PROTECTED WHEN COMPLETED - B
r c, r 2 G v. (C'.Y c"F I + 1 u er t. 1 C3 S"T'c r."" C3
E-mail Address (for direct deposit notification) (Area code) Telephone Number Extension
3236
Street Address, Office Number, R.R., or P.O. Box
City, Town I Province/Territory Postal Code
Request applies to the following project(s):
Project Number
Privacv Notice:
Or\k- z If-- ;
Program Name
K14 L Is47
Project Location
The information you provide on this form is collected by Employment and Social Development Canada (ESDC) under the
authority of the Department of Employment and Social Development Canada Act (DESDC Act) to effect and administer direct
deposit payments for grants and contributions. ESDC will monitor the initial deposits and may cross reference with other
funded programs for verification purposes of the banking information. Participation is voluntary. However refusal to provide this
information will result in not receiving payments through the direct deposit system.
Your personal information will be retained in Personal Information Bank: ESDC PPU 298 and administered in accordance with
the DHRSD Act, and the Privacy Act. You have the right to the protection of, and access to, your personal information.
Instructions for obtaining this information are outlined in the government publication entitled Info Source, which is available at
the following web site address: infosource.ac.ca. Info Source may also be accessed on-line at any Service Canada Centre.
SC NAS5050 (2016-09-005) E Page 1 of 2 Canada
Authorization
I, undersigned, am legally entitled to sign the agreement on behalf of the organization and confirm that the information included
in this form is accurate and complete. Uwe authorize ESDC to deposit, in the account indicated in this form, all payments in
accordance with the terms and conditions of the agreements concluded with ESDC for the indicated project(s). I/we authorize
ESDC and Public Services and Procurement Canada (PSPC) to proceed with the verification of this account by the deposit of
an amount of $5.00 of the project funds and I agree to confirm, upon request by ESDC, that the deposit has been done in the
right account. I understand that this Due Diligence procedure is mandatory. Me also authorize ESDC to monitor initial
deposits and cross reference with other funded programs for verification purposes of the banking information.
Printed Name
2v,. e-1 1,e Cns+--3 vt.-- n p
Printed Name
Printed Name
Financial Information
Signa re
ignature
Signature
A blank 'VOID' cheque must be included with the form.
Date (yyyy-mm-dd)
Zoll -0; -IS
Date (yyyy-mm-dd)
Date (yyyy-mm-dd)
1. This isthe cheque ro, le.,ti 3. This Is the bank
number (do not enter vocarcrrm rs
cUr.rew.csob-tH9c
r,,,.„•i. a.rewKama.. COO" account number.
thisnumberi. ri:,s.Mvco
an- iRna a
Ad-, 971 pov,r, A 0. This Is the financial
2 This istM branch ZL`1 W institution number (3
number (5 digits). M999a :99999 999: 999 999 9 `
gRmin
digits).
If you are not submitting a voided cheque, have your financial institution complete the following information.
Branch Number
Account Number
Financial Institution Stamp
Institution Number
Name(s) of account holder(s)
ESDC is not responsible for the problems which could arise if the provided information is inaccurate or
incomplete. The department can refuse a request for registration.
SC NAS5050 (2016-09-005) E Page 2 of 2
THE CORPORATION OF THE TOWN OF TILLSONBURG
VENDOR NO:
TOTAL '
NAME:
THE CORPORATION OF THE TOWN OF TILLSONBURG
200 BROADWAY
TILLSONBURG, ON N4G 5A7
PAY
TO THE
ORDER
OF
CHEQUE D.
NET AMOUNT PARI
lm Canada Trust
220 DUNDAS Sl
LONDON, ON N6A1H3
DATE
047493
047493
THE CORPORATION ZTTH:TOWN OF TILLSONBURG
PER
PER
in 0L. 749 311' 1:000 L 2-0041: 684 2- 5 2 L 59 2 SI"
THE CORPORATION OF THE TOWN OF TILLSONBURG 047493
PRINTER
ID # 1005 - B
PAPji-9 r
ChDM CAL ';ENSi rMTY PR;NT LC(,K COAI NG
PFINT CMAf3ACjfiPl.FDC COLC'UnED EACKORa!ND
CAP,ACTtRl5T*)Fi DU PAPTR FUG{--PNL-- MORIQU-
S N'161UTL CHO.CGLIC FIRRH FLUU'.FS'ClNTc5
c-, OUC11F FR;Nl LOCK N%)'iIRLEG
Endorsement - Signature or Stamp PEJAMPPIM - FONLI COLOPtEndossement - Signature ou timbre
BACKNERSO