REQUEST FOR DIRECT DEPOSIT IN CANADA …

1 Your Social Insurance NumberType of Payment Check (9) one or both boxesUsual First Name and InitialLast NameSECTION D - AUTHORIZATIONXS ignatureDateSECTION C - DIRECT DEPOSIT INFORMATIONzFinancial institution name, address and postal code(stamp may be used)Name(s) of account holder(s)Branch NumberInstitution NumberAccount NumberCheck (9) one boxWork telephone number(if applicable) Address (No., Street, Apt., Box, )Province or Territory (if CANADA )CountryHome telephone numberPostal CodeCity Ce formulaire est disponible en fran ais - ISP-1011 FISP 1011-12-06 Internet VersionTo sign up for or change DIRECT DEPOSIT information, choose one of the following a personalized cheque from your chequing account to this form.

2 Write "VOID" across the front of the blank chequeand put your Social Insurance Number on the back. We will use the financial information on the cheque to set up the blocks when completed - APersonal Information Bank SDC PPU 146 Human ResourcesDevelopment CanadaD veloppement desressources humaines CanadaNote:To REQUEST DIRECT DEPOSIT for accounts within the United States, please call our toll-free number 1 800 FOR DIRECT DEPOSIT IN CANADAC anada Pension Plan and Old Age SecurityOld Age SecurityCanada Pension PlanStartDirect DepositChangeinformation on DIRECT DepositORSECTION A - TO START OR CHANGE DIRECT DEPOSITSECTION B - INFORMATION ABOUT YOUDayMonthYearI, hereby authorize the Receiver General for CANADA to DEPOSIT ,until further notice, the payment(s) described above into myaccount, as indicated in Section C, by means of DIRECT CANADA OfficesYour form(s) should be mailed to the nearest Service CANADA office.

3 These offices are shown below. Ifyou need any help while you are completing your form(s) and you are inCanada or the United States,you can phone our toll-free number1 800 277-9914. For people with speech or hearing impairmentsusing a teletypewriter device TTY, call1 800 255-4786. Please have your social insurance :If you are applying from outside of CANADA , mail your form(s) to the office in the provincewhere you last (Timmins)Service Bag 2013 Timmins ONP4N 8C8 ONTARIO (Chatham)Service Box 2020 Chatham ONN7M 6B2 MANITOBA AND SASKATCHEWANS ervice Box 818 Station MainWinnipeg MBR3C 2N4 ALBERTA / NORTHWEST TERRITORIESAND NUNAVUTS ervice Box 2710 Main StationEdmonton ABT5J 4C2 BRITISH COLUMBIA AND YUKONS ervice Box 1177 Victoria BCV8W 2V2 NEWFOUNDLAND AND LABRADORS ervice Box 9430St.

4 John's NLA1A 2Y5 PRINCE EDWARD ISLANDS ervice Box 20105 Sherwood Postal OutletSherwood PEC1A 9E3 NOVA SCOTIAS ervice Box 1687 Station CentralHalifax NSB3J 3J4 NEW BRUNSWICKS ervice Box 250 Fredericton NBE3B 4Z6 QUEBECS ervice Box 1816 Quebec QCG1K 7L5 ONTARIO (Scarborough)Service Box 5100 Postal Station "D"Scarborough ONM1R 5C8Ce formulaire est disponible en fran ais - ISP-3501 FISP-3501-12-06 EInternet VersionHuman ResourcesDevelopment CanadaD veloppement desressources humaines CANADA