Lithuania Direct Deposit Enrolment Form

Part A

Please print clearly.

Please keep the appropriate federal government department informed of any change to your mailing address.

1. Surname:
2. Given name and initial(s):
3. Address (full address required):
4. Is this a new address? Yes/No
5. Telephone number:

Part B

1. Select the payment(s) you wish to receive by direct deposit.
2. Enter the number associated to each type of payment you wish to receive.

Service Canada

• Old Age Security (OAS): Yes/No
• International Agreements - OAS: Yes/No
• Canada Pension Plan (CPP): Yes/No
• International Agreements - CPP: Yes/No
• Social Insurance No. (9 digits):

• Canadian Government Annuities: Yes/No
• Contract No. (10 digits):

Veterans Affairs Canada

• Veterans Affairs Pension or Award: Yes/No
• War Veterans Allowance: Yes/No
• Veterans Affairs Financial Benefits: Yes/No
• File No. (7 digits):

Compensation

• Canadian Forces Pension: Yes/No
• Public Service Pension: Yes/No
• Royal Canadian Mounted Police (RCMP) Pension: Yes/No
• Judges' Pension: Yes/No
• Pension No. (9 digits):

• Members of Parliament Retiring Allowances: Yes/No
• Personal Record Identifier (9 digits):

Part C

1. Must be completed by the financial institution or post office where you want your money deposited.
2. Select the appropriate account type.
   
   • Bank Information Code (BIC/SWIFT): Yes/No
     No. (8 or 11 characters):
   • International Bank Account Number (IBAN): Yes/No
     No. (20 characters):
3. Name(s) of account holder(s):
4. Financial institution name, address and postcode (stamp may be used):
5. Signature of financial institution official:
   Date (yyyy-mm-dd):
6. Telephone number of financial institution:
7. I, as the person entitled to receive the aforementioned payment(s) and in lieu of my receiving a Receiver General cheque for it, hereby authorize the Receiver General for Canada to convert Canadian Dollars to Lithuanian litai and to deposit the payment(s), until further notice, into my account noted herein by means of Direct Deposit. I hereby agree to accept the exchange rate applied to the payment(s). I also agree that neither the Canadian government nor its agents shall be liable to myself or any third party for any special, consequential or incidental damages arising from delay.

   Signature:
   Date (yyyy-mm-dd):

Mail the Form

Cheque Redemption Control Directorate
P.O. Box 7000
Matane, QC
G4W 4T5
Canada