Revised January 2017 HR Form
Bank Information Form
Payroll Direct Deposit & City Payments
Electronic T4
Legal First Name and Middle Initial:
B
y completing this form you are authorizing the City of Surrey to deposit your pay into the specified account and to
utilize your specified account for expense reimbursement.
If you worked for the City in the past and you would like to use the same banking information we have on file for you,
please check this box to re-authorize your bank account information:
T
here are 2 ways to provide the data required on this form.
1. Attach a blank, voided cheque from your account. If the cheque is not personalized you must sign the
cheque. The cheque can be an original, a PDF, a scanned copy or a photo. The relevant informatio
n
m
ust be clearly legible.
2. If you do not have a cheque, or you wish to deposit into a non-chequing account, your financial
institution can complete this form (including a bank stamp) or you can include a screen shot from your
online banking information that clearly shows this information.
B
ank Account Information: Bank Stamp:
T
he City of Surrey requires this form to be completed and returned before you start employment.
T
his form authorizes the City to provide you with an electronic T4. If you wish to receive a paper T4, please go to
PeopleSoft Self-Serve after you commence employment.
I
nstructions:
1. Complete each box on the form.
2. Information provided on this form is stored and used for HR purposes linked to payroll and benefit administration.
3. This form (once completed) should be uploaded using our secure system. OR: If you prefer not to upload this
document, it can be faxed (604-591-4517), mailed or physically returned to City of Surrey HR, 13450-104
th
Ave.,
S
urrey BC V3T 1V8. The City of Surrey recommends that you do not email the required personal informatio
n
u
sing unsecured systems.
