PERSONAL PRE-AUTHORIZED
DEPOSIT AND PAYMENT AGREEMENT
Collection of this personal information by Advanced Education is done under the authority of section 33(c) of the Freedom of Information and Protection
of Privacy Act (Alberta) (“FOIP”) to administer your Alberta Student Loan. The use and disclosure of your personal information is managed in accordance
with FOIP. If you have any questions about the collection, use or disclosure of this information, call the Alberta Student Aid Service Centre toll free in
North America at 1-855-606-2096, TTY for the hearing impaired at 1-855-306-2240, toll free outside of North America at (International Access Code) +
800-2-529-9242. You can also mail your questions to the Alberta Student Aid Service Centre, Executive Customer Assistance Department, PO Box 4050,
Mississauga Stn A, Mississauga ON L5A 4M9.
Complete this form and mail to the Alberta Student Aid Service Centre at the address below or fax to 1-866-236-2332. The Alberta Student Aid Service
Centre will administer any pre-authorized deposits and payments on behalf of the Government of Alberta.
Alberta Student Aid Service Centre
P.O. Box 4050 • Mississauga, STN A • Mississauga, ON • L5A 4M9
E&OE AB-PAPPform(E)(vers 5.4)
1. Your Personal Information
First Name (current legal name)
Telephone Number (format: 999-999-9999)
2. Your Bank Account Information
Provide your bank account information. The account must be at a Canadian bank held in your name solely or jointly. If you need help,
contact your bank.
Attach a bank-veried direct deposit/payment form or a void cheque.
Name of Financial Institution
Account Number
IMPORTANT: Please note that changes to your bank account need to be received at the Alberta Student Aid Service Centre ve (5)
business days BEFORE your next Alberta student loan payment or deposit is due or they won’t be effective until the following month.
3. Pre-Authorized Deposit Agreement
You, the Borrower, hereby authorize the Alberta Student Aid Service Centre to deposit the proceeds of your current or any future
Alberta Student Loan(s) as dened in the Master Student Financial Assistance Agreement into your Bank Account identied above.
4. Pre-Authorized Payments (for Loans in Repayment)
You, the Borrower, hereby authorize the Alberta Student Aid Service Centre to debit your bank account by the amount of
$ _____________________, starting in ____________/_____________ (insert month and year), in accordance with the terms of your Master
Student Financial Assistance Agreement. These payments will be withdrawn by the Alberta Student Aid Service Centre on behalf of the
Government of Alberta. Note: Payments will be withdrawn on the same day each month, until the loan has been paid in full.
5. Your Rights and Obligations
You, the Borrower, have certain recourse rights if any deposit or payment does not comply with this Pre-Authorized Deposit and
Payment Agreement. You, the Borrower, may revoke your authorization at any time by providing written notice to the Alberta Student
Aid Service Centre at least ve (5) business days prior to your next scheduled Alberta Student Loan deposit or payment. To obtain
more information on your rights, please contact your nancial institution, or visit www.payments.ca. You can also contact the
Alberta Student Aid Service Centre in writing, by phone toll free in North America at 1-855-606-2096, TTY for the hearing impaired
at 1-855-306-2240, toll free outside of North America at (International Access Code) + 800-2-529-9242, or by fax at 1-866-236-2332.
Borrower’s Signature
SIGN HERE
Middle
Initial
Last Name (current legal name)
Alberta Student Loan Number
Social Insurance Number
Branch/Transit Number
Bank Number
Today’s Date
Day Month Year
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