Direct deposit request form

Protected "A" when completed.

General instructions

This fillable form has been designed to make it easier for you to enrol in direct deposit. Please note that the completed form cannot be saved on your computer. Please print, sign and email or mail the completed enrolment form. There are two available formats, HTML and PDF (354 KB), both of which can be filled out on screen, printed and signed.

• This form can only be used for payments deposited in Canada or the USA.
• If you wish to revoke your direct deposit authorization or change your financial institution, the branch of your financial institution or your account number, you must complete this form again. do not close your present direct deposit account until you receive the first payment in your new account.
• All payments over $5,000 are subject to a one-time test deposit to ensure the payment is made to your business's bank account. This means that your first payment of over $5,000 may be delayed while the Canadian Space Agency confirms the accuracy of your banking information. A payment of under $10 will be deposited into your account. Once you confirm that you have received the small payment, the balance of the payment will be deposited into your account. This process will only occur once unless you change your banking information.
• All payment notifications will be sent to the email address provided. Please ensure your address is correct and up to date. Should the direct deposit fail for any reason, a cheque will automatically be produced and mailed to the address provided.
• Until your direct deposit information has been updated, you will continue to be paid by cheque.
• To submit your change of address or ask any questions about the form, please use the following address: fichierfournisseur-vendorrecord@asc-csa.gc.ca.

Privacy notice

Personal information is collected under the Financial Administration Act, Subsections 17(1) and 35(2). The Canadian Space Agency shall disclose information to relevant federal institutions and your financial institution. Direct deposit payments cannot be made without provision of requested information. Personal information is protected in accordance with the Privacy Act, and as described in Personal Information Bank CSA PPU 045 – Grants and Contributions – Research Component. Under the Act, you have the right to access and correct your personal information, if erroneous or incomplete. Third party information provided by companies shall be protected, used and disclosed in accordance with the Access to Information Act.

Part A ‑ General information

Purpose of the request (required)

Start direct deposit

Change direct deposit information

Stop direct deposit

Applicant's information

Legal name of the applicant (business or individual applicant name) (maximum of 60 characters) (required)

Operating business name (maximum of 60 characters)

Name of parent company, if applicable

Address (maximum of 60 characters) (required)

City (maximum of 30 characters) (required)

Province/State: (required) Select one... Alberta British Columbia Manitoba New Brunswick Newfoundland-and-Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Country

Select a province or state

Postal code/ZIP code (no space) (required)

Telephone 1 (999‑999‑9999) (required)

Telephone 2 (999‑999‑9999) (required)

Email address 1 (maximum of 60 characters) (required)

Email address 2 (maximum of 60 characters) (required)

Provide the following if applicable:

Business or GST number

PST number

Social Insurance Number (individuals only)

Print: Part A ‑ General information

Résumé des informations générales pour l'impression

• Purpose of the request:

Applicant's information

• Legal name of the applicant:
• Operating business name:
• Name of parent company:
• Address:
• City:
• Province/State:
• Country:
• Postal code/ZIP code:
• Telephone:
• Telephone 2:
• Email address:
• Email address 2:

Provide the following if applicable

• Business or GST number:
• PST number:
• Social Insurance Number:

Part B ‑ Banking information

1. Cheque No. ‑ not required.
2. Branch No. ‑ 5 digits.
3. Institution No. ‑ 3 digits.
4. Account No. ‑ as shown on your cheque.

A void cheque with "VOID" written on it will be attached to the form (Canada only)

Branch No. (for USA: ABA Direct Deposit Routing number) (required when void cheque is not attached)

Institution No. (required when void cheque is not attached)

Account No. (required when void cheque is not attached)

Swift code for USA

Account type (required)

Chequing

Savings

Name(s) of account holder(s) (if different from legal name of the applicant) (maximum of 60 characters)

Financial institution name, address and postal code (required when void cheque is not attached)

Telephone number of financial institution (999‑999‑9999) (required when void cheque is not attached)

Confirmation of financial institution official

Date (YYYY-MM-DD)

 

Financial institutions stamp here (required when void cheque is not attached)

 

Résumé des informations bancaires pour l'impression

• A void cheque with "VOID" written on it will be attached to the form: No
• Branch No.:
• Institution No.:
• Account No.:
• Swift code for USA:
• Account type:
• Name(s) of account holder(s) (if different from legal name of the applicant):
• Financial institution name, address and postal code:
  
• Telephone number of financial institution:

Confirmation of financial institution official

• Date (AAAA-MM-JJ) :
• Financial institutions stamp here

Part C ‑ Consent

I, the undersigned, have read the Privacy and Third Party Notice, and I consent to the collection, use and disclosure of my information as described therein.

I, as an authorized representative of this business, grant the Receiver General for Canada the right to deposit future payment(s) from the Canadian Space Agency directly into the bank account specified until further notice.

Name of the authorized representative (applicant) (60 caractères maximum)

Signature of applicant

When printed, sign here.

Date

2024-11-22

Print: Part C ‑ Consent

I, the undersigned, have read the Privacy and Third Party Notice, and I consent to the collection, use and disclosure of my information as described therein.

I, as an authorized representative of this business, grant the Receiver General for Canada the right to deposit future payment(s) from the Canadian Space Agency directly into the bank account specified until further notice.

Résumé du consentement pour l'impression

• Name of the authorized representative (applicant):
• Signature of applicant:
• Date: 2024-11-22

Part D - Send form

Please ensure that you sign the form before mailing it.

To ensure that your information is not visible to other users of this computer, please click on "Clear data" after the form has been printed.

Where to send completed forms

By email:
fichierfournisseur-vendorrecord@asc-csa.gc.ca

or

By mail:
Accounting Operations and Financial Policies – Vendor Records
Canadian Space Agency
6767 Route de l'Aéroport
Borough of Saint-Hubert
Longueuil, Quebec J3Y 8Y9