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Direct Deposit Registration - AISH

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                                                                                                                    Direct Deposit Registration


The information you provide on this form is collected under the authority of the Assured Income for the Severely Handicapped (AISH) Act, and is in compliance with the
Freedom of Information and Protection of Privacy Act. This information will be used solely for the purpose of depositing AISH benefits directly into the requested account.
We will not release this information for any other purpose. If you have any questions about the collection of this information, you may contact the AISH worker.

Mailing Address                                                                                                                  For AISH Office Use Only
                                                                                                                            AISH Office/Unit/Caseload


                                                                                                                            File Number



Instructions
l Please complete this form to have the AISH benefits deposited directly into the requested account.
l Funds will be deposited in only ONE account.

Client and Account Holder Information See sample cheque on back to complete the following information:

A. Name of Account Holder                                                                           Name of Client if different than Account Holder


   Home Address


   City/Town                                                             Province/Territory         Postal Code             Telephone Number (e.g., 9999999999)
                                                                          1

Bank Information
B. Name of Bank, Credit Union, etc.


C. Bank Address


Type of Account (please check one)                D. Branch Number                     E. Bank Number                       F. Account Number
     Chequing              Savings

                       Bank Stamp                              l If you have a personalized cheque for the account, send one with "VOID" written
                                                                 on the front (you do not need to get a bank stamp or bank officer's signature).
                                                                                                                    OR
                                                               l If you do not have a personalized cheque for the account, take this form to where
                                                                 the account is located. Have a bank officer sign and stamp to verify the above
                                                                 banking information or provide the information on their own form.



                                                                       Bank Officer's Signature                     Telephone Number                  Date (yyyy/mm/dd)


I authorize Alberta Seniors and Community Supports to make arrangements to deposit payments received from AISH into the account shown
above. I understand I must notify the AISH worker immediately if I change or close the account.



                Signature of Account Holder                                        Printed Name of Account Holder                                Date (yyyy/mm/dd)

                                                                     For AISH Office Use Only
         Entered by: (initials)          Date Entered (yyyy/mm/dd)                                Verified by: (initials)          Date Verified (yyyy/mm/dd)




DS2443 (2010/12)                                                                                                                                                    Page of
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                                                    Sample of Cheque
       A           Shirley Smith                                                                  159
                   #102, 10222 - 102 Street                                Date
                   Edmonton, Alberta T6P 1L9
                   PAY TO
                   THE ORDER OF
                                                                                         $
                                                                                             /100 Dollars
       B           ROYAL BANK OF CANADA
                   107 Street & 107 Avenue Branch
       C           10707 - 107 STREET
                   EDMONTON AB T6A 3P8

                      159 :        777777 888 : 9999999



                                         D             E               F
                                                                The length of
                                                                account number
                                                                may vary




                                                    For AISH Office Use Only

                                                     Worker Comments




DS2443 (2010/12)                                                                                                  Page of
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