Notice of Cancellation of Agreement by yjs11983


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									                                                                                        BENEFIT PAYMENTS FORM
                                                                          PRE-AUTHORIZED PAYROLL DEBIT (PAD) AGREEMENT

1. Employee information: (Please print clearly)

                UVIC ID: V00                                                   UVIC DEPT:

     Mailing Address:

                       City:                                  Province:                     Postal Code:

Telephone Number:                                                                 E-mail:

2. Bank Account Information (must be the same as Payroll Direct Deposit information)

If you wish to change your Direct Deposit Information please complete the HRIS Direct Deposit Form and submit to Payroll
Form available on-line at                   HTTPS://Web.Finance.Uvic.Ca/Forms/HRISDirectDeposit.PDF

3. Pre-Authorized Debit (PAD) Details

I/We, the Payor, authorize the University of Victoria to debit my account (same bank account used to deposit payroll proceeds) for
payments of Benefits. Per the terms outlined below, and pursuant to the account information, such time as ten (10) days prior written
notice must be provided to UVic Accounting Services, the HRIS/Payroll Office, requesting termination of Pre-authorized Payment Service.
To obtain the Cancellation Notice form, visit HRIS web-site at

I/We hereby waive any requirement for pre-notification of changes in the amount - due to adjustments, rate increases, etc. and/or
payment dates of Pre-Authorized Debits drawn against my/our Account and my/our Financial Institution in accordance with this

I/We understand that, for each benefit month, the payroll debit will be applied to my account on the 1st of each month, or on the following
 business day. This direct debit will continue until my return to work or until a cancellation notice is received in the HRIS/Payroll office.

Anticipated # of Months                        Total Monthly Benefit Amount                            Leave Start Date


               Date                                    Signature                     Signature of Joint Account Holder (If Applicable)

I/we warrant and guarantee that all persons whose signature are required to sign on this account have signed this agreement.

You have certain rights if any debit does not comply with this agreement. For example, you have the right to receive
reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more
information on your rights, contact your financial institution or visit

When the form is complete, mail, or fax to:                   University of Victoria - Accounting Services
                                                              HRIS/Payroll Office
                                                              P.O. Box 3040 STN CSC
                                                              Victoria, BC V8W 3N7                   Fax#: 250-472-5196

    342c960b-e056-4144-a1c6-0630dc03755a.xls                                                                                                    Dec/09
                                                   PRE-AUTHORIZED PAYROLL DEBIT

                                                    CANCELLATION NOTICE FOR
                                                       BENEFITS PAYMENTS

       TO:      UNIVERSITY OF VICTORIA - HRIS/Payroll Office             (Payee)
     FROM:       UVIC ID#: V00                              DATE:

    I/We,                                                     , cancel my/our pre-authorization
    of payroll debits in the amount of $                       (Enter Amount) against my/our account number
                                       (Enter Account Number - should be the same back account used to deposit
    payroll proceeds) effective on                     (Enter Date - Must be received 10 days or more prior
    to the pay date).

    I/We acknowledge that this cancellation does not terminate any other obligations that I/We may
    have with the Payee.

                                   Payor/Valid Signing Authority (ies)

    Where the Payor's account agreement requires the signature of two or more signing authorities,
    the signatures of all such persons are required for the purposes of this Cancellation Notice.

    Note: Subject to the terms of any agreement between a payor and Payee including their Payor's PAD
    Agreement, a Cancellation Notice may be provided to a Payee by way of registered mail, telephone,
    Internet, e-mail, fax or prepaid courier and must be provided in compliance with the notice
    requirements for cancellations, if any, set out in the applicable Payor's PAD Agreement.

342c960b-e056-4144-a1c6-0630dc03755a.xls                                                                  Dec/09

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