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Direct Deposit Form - HR2648 2

This document is an application form for direct deposit related to Employment and Assistance or Employment and Assistance for Persons with Disabilities in British Columbia. It collects personal and banking information for electronic funds transfer and outlines the authority under which the information is collected. Clients are advised about the implications of direct deposits and must provide a signature to authorize the request.

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116 views1 page

Direct Deposit Form - HR2648 2

This document is an application form for direct deposit related to Employment and Assistance or Employment and Assistance for Persons with Disabilities in British Columbia. It collects personal and banking information for electronic funds transfer and outlines the authority under which the information is collected. Clients are advised about the implications of direct deposits and must provide a signature to authorize the request.

Uploaded by

lisamunjo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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EMPLOYMENT AND ASSISTANCE OR EMPLOYMENT AND

ASSISTANCE FOR PERSONS WITH DISABILITIES


APPLICATION DIRECT DEPOSIT REQUEST
NOTICE: Information on this form is collected under the authority of the Employment and Assistance Act or Employment and CLIENT FILE NUMBER
Assistance for Persons with Disabilities Act and will be used for administrative purposes related to electronic funds transfer.
The information on this form is subject to the provisions of the Freedom of Information and Protection of Privacy Act and any
questions regarding this form should be directed to your Employment Assistance Worker at your local Employment and
Assistance Office.

EMPLOYMENT AND ASSISTANCE OFFICE INFORMATION PLEASE PRINT CLEARLY


EMPLOYMENT AND ASSISTANCE OFFICE

EMPLOYMENT AND ASSISTANCE OFFICE ADDRESS POSTAL CODE

CLIENT NAME
LAST NAME FIRST NAME INITIALS

EMAIL ADDRESS

MAILING ADDRESS
STREET CITY

PROVINCE POSTAL CODE TELEPHONE

BRITISH COLUMBIA
NOTE: Money deposited to your bank account can be taken from your account by parties who have a
court order or judgement against you.
The Province of British Columbia is hereby requested to credit payments due to the below account with the Financial
Institution designated, until cancelled in writing by me. I agree the ministry may discontinue/suspend direct deposit at any
time.
SIGNATURE DATE (YYYY MMM DD)

Attach a personalized cheque with “VOID” written on the front OR have your financial institution
complete this section.
BANK OR FINANCIAL INSTITUTION
JOINT ACCOUNT? YES NO
NAME OF PERSON(S) ON ACCOUNT

BANK OR FINANCIAL INSTITUTION

STREET CITY

PROVINCE POSTAL CODE TELEPHONE

BANK NUMBER TRANSIT NUMBER ACCOUNT NUMBER

Bank or Financial Institution Verification (Required only if no VOID cheque is attached) DATE SIGNED (YYYY MM DD)
Signature and Bank Domicile Stamp Confirming Accuracy of Transit and Account Number and Authenticity of Signature

HR2648(15/03/16)
Security Classification: MEDIUM SENSITIVITY Page of

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