Direct Deposit / Pre-Authorized Debit Form
Client Name:
Account #:
00016
608
Transit
Institution number
Identifier
Sub
Account number
This form can be used in place of a void cheque for setting up or modifying direct
deposit or pre-authorized debit or payment transactions. Please take this document to your
Billing/Deposit Company to initiate or modify the following pre-authorized transaction:
Deposit/Billing Company Information
New Change Cancel
Company Name:
Street Address:
City:
Province: Postal Code:
Please accept this document as my authorization to set up or modify the following pre-
authorized transaction:
Direct Deposit Pre-authorized Debit or Payment
Payroll Utility
Insurance Cable/Phone
Pension Loan/Mortgage
Investment/Annuity Investment
Other: Insurance
Other:
Frequency:
Frequency:
Reference #:
Reference #:
Amount:
Amount:
$
Next Payment Date: Next Payment Date:
dd/mm/yyyy dd/mm/yyyy
Authorized Signature(s)
Client Signature
Date
Joint (if applicable)
Date
For Government of Canada deposits, please speak to your payroll office or visit www.ccra-adrc.gc.ca and use form #520745 ‘Direct Deposit
Enrolment Request’.
*CS Alterna Bank operates as Alterna Bank.
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signature
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signature
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