Pre-authorized debit and direct deposit form (Atlantic Fisheries Fund)
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Recipient name:
Atlantic Fisheries Fund project number:
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A - Pre-authorized debits - Please attach a voided cheque and complete the following: |
| Name of account holder(s) (If different from above) |
| If you are not providing a voided cheque, please have the following information completed and confirmed by your financial institution: |
Branch no.:
Institution no.:
Account no.:
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Name(s) of account holder(s):
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Financial institution:
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Address:
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Telephone no.:
Signature of financial institution official
Date:
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| All information obtained by Fisheries and Oceans Canada (the department) will be treated in accordance with the access to information act and the privacy act. |
B- Direct deposit authorization: |
Progress and final payments of the contribution can be deposited directly in the above-mentioned bank account. Please provide your email address for notification. |
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Email address:
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I/We hereby authorize the Department to debit the bank account identified above, as per the repayment terms of the contribution agreement(s) and any subsequent amendments. I/we hereby authorize the Department to credit the bank account identified above. I/We hereby authorize the Department to debit the bank account identified above with a service fee of $15.00 if a PAD is returned due to insufficient funds. I/We may revoke my/our authorization at any time, subject to providing written notification from me/us of its change or termination. This notification must be received by the 15th day of the month prior to the next scheduled payment. To obtain a sample cancellation form, or for more information on my/our right to cancel a PAD agreement I/we may contact my/our financial institution or visit Payments Canada. I/we acknowledge that this cancellation does not terminate any obligation that I/we may have with the Department. I/we acknowledge that I/we must continue to make payments according to the contribution agreement by a method acceptable to the Department until the contribution is repaid in full. Should I/we stop making payments, I/we will be in default of the contribution agreement(s). I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution or visit Payments Canada. |
Signature of authorized signing officer(s)
Date:
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Return form by mail to: Atlantic Fisheries Fund - Polaris-P430 |
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