National Student Loans Service Centre (NSLSC)
P.O. Box 4030
Mississauga, ON L5A 4M4
Tel.: 1-888-815-4514
Fax: 1-866-658-8801
Bank Account Information Change Request for Electronic Disbursements
1. Personal Information (Please print clearly)
First Name:
Last Name:
SIN:
Street Address:
City / Province
Postal Code:
Telephone Number:
2. Bank Account Information (Please print clearly)
Your financial assistance will be electronically deposited into the bank account you enter below. The
information you send must be for an account at a Canadian bank held in your name solely or jointly.
Further changes to your bank account information must be provided in writing. Please attach or fax a copy
of a void cheque from this bank account.
Financial Institution Number/Name:
Account Number: Branch Transit Number:
Name of Account Holder(s):
Your rights and obligations respec
ting your personal and banking information are governed by the terms
of your Master Student Financial Assistance Agreement (MSFAA) with Canada and the associated
Province or Territory on your MSFAA:
You authorize Canada and your Province or Territory to make electronic withdrawals from this
bank account (or any other bank account you have provided in writing) when payments become
due, under the terms of your MSFAA. These withdrawals will be made by the NSLSC on behalf
of Canada and your Province or Territory, as applicable.
You waive any requirement to receive written pre-notifications of any withdrawals.
You may revoke your withdrawal authorization with 30 days notice to the NSLSC. If any
withdrawal does not comply with the terms of your MSFAA and this agreement, you have certain
recourse and reimbursement rights. To obtain a cancellation form, visit the NSLSC Tool Box of
the NSLSC section at CanLearn.ca, or contact the NSLSC.
By signing below, you ratify your revocable authority and directions above and granted in your MSFAA
to Canada and your Province or Territory, and to any financial institution which holds such a bank
account, to exchange the financial information necessary to facilitate such Personal Pre-Authorized
Debits according to the Canadian Payments Association Rule H1. To review this rule or for more
information on any of your rights, please visit
www.cdnpay.ca.
Signature of Account Holder:
Signature of Joint Account Holder (if applicable):
Name:
Name:
Date:
Date:
NSLSC-PAPP-ISchange(E)(vers 6.1)
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