Direct Deposit Authorization
Community Services for Electronic Funds Transfer (EFT)
www.novascotia.ca/coms DCS-201 20122016 .07
1 Select what would you like to do
Start direct deposit
Change direct deposit information
Stop direct deposit Effective date (dd/mm/yyyy):
2 Provide your contact information
Name: Date of birth (dd/mm/yyyy):
Address:
Home Phone (xxx-xxx-xxxx): Cell Phone (xxx-xxx-xxxx):
Email address: ________________________________________________________________________________________________________
(for Electronic Funds Transfer (EFT) payment information)
3 Give your banking information
Note: This section is not required if you are stopping direct deposit.
OPTION 1
Please attach a personalized blank cheque with your
bank information on it. Write void across the front.
4 Authorize electronic payment
I authorize the Province of Nova Scotia to start, change or stop
deposit, by electronic funds transfer, payments owed to me by
the Province of Nova Scotia and, if necessary, to debit entries
and adjustments for amounts deposited electronically in error.
The Province will deposit the payments in the banking account
designated above.
Note: If I submit my email address to receive EFT payment
information, I will receive EFT payment information by
email for all payments from Department of Community
Services that require no additional reporting.
Signature: ________________________________________
Date (dd/mm/yyyy): _________________________________
5 Return completed form and void personalized cheque (if applicable) to your caseworker
Questions? Call your local office.
Office use only
Person ID
Date Entered (DD/MM/YYYY)
Regional Financial Clerk Name
Regional Financial Clerk Signature
Financial Institution
Stamp
:
OPTION 2
If you do not have a blank cheque, have your bank complete the following.
Name of bank:
Branch address:
Transit No.: Institution No.:
Account No.:
Phone number (xxx-xxx-xxxx):
Authorized representative name:
Authorized representative signature:
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