Form NWT9005 "Pre-authorized Payment Form" - Northwest Territories, Canada

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Download Form NWT9005 "Pre-authorized Payment Form" - Northwest Territories, Canada

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NWT Student Financial Assistance
PRE-AUTHORIZED PAYMENT FORM
1. STUDENT INFORMATION
Last Name
First Name
Middle Name(s)
City/Community
Mailing Address
Territory/Province
Postal Code
Phone Number
Email Address (print clearly)
Date of Birth (YY/MM/DD)
2. PAYEE INFORMATION
, hereby authorize the Government of Northwest Territories –
I,
Student Financial Assistance to debit my account on the
1st or
15th or both the
1st and 15th of each month in the amount of
$
effective
. These payments will be applied to my
or
student loan.
3. BANKING INFORMATION
Name of Financial Institution
Branch Address
Bank Number
Transit Number
Account Number
4. AUTHORIZATION
(must be signed)
1.
In this Authorization ‘I’, ‘me’ and ‘my’ refer to each Account-Holder who signs below.
2.
I authorize the Government of Northwest Territories (GNWT) to debit (a ‘Pre-Authorized Debit’) my account indicated above at the Financial
Institution branch indicated above for the purpose of obtaining payment for my NWT Student Loan.
3.
I may revoke this authorization at any time by submitting written notice within one month. I agree that revocation of this authorization does
not terminate any contract for the loan or money that exists between me and the GNWT.
4.
I agree that the Financial Institution is not required to verify that any Pre-Authorized Debit has been drawn in accordance with this
authorization, including the amount, frequency and fulfillment of purpose of any Pre-Authorized Debit.
5.
I agree that the delivery of this authorization to GNWT constitutes delivery by me to the Financial Institution.
6.
I will inform the GNWT, in writing, of any change in the Account Information provided in this authorization at least five (5) working days prior
to the next due date of the Pre-Authorized Debit above.
7.
I warrant that all persons whose signatures are required to sign on the Account have signed this authorization.
This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP), Section 40.(a) and (c)(i)
and the Student Financial Assistance Act and Regulations. The information will be used to determine my eligibility for the Northern Bonus and for
the general administration and enforcement of this program. The privacy provisions of ATIPP protect my information.
Personal information is defined under ATIPP, Section 2. All applicants have the right to examine and request correction of his or her records and to
request a review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact the Manager,
Divisional Financial Services, Income Security Programs Division, Department of Education, Culture and Employment, Box 1320, Yellowknife, NT,
X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
X
Account Holder's Name - Print Name
Account Holder’s Signature
Date - YY/MM/DD
PAGE 1 OF 1
NWT9005/0617
NWT Student Financial Assistance
PRE-AUTHORIZED PAYMENT FORM
1. STUDENT INFORMATION
Last Name
First Name
Middle Name(s)
City/Community
Mailing Address
Territory/Province
Postal Code
Phone Number
Email Address (print clearly)
Date of Birth (YY/MM/DD)
2. PAYEE INFORMATION
, hereby authorize the Government of Northwest Territories –
I,
Student Financial Assistance to debit my account on the
1st or
15th or both the
1st and 15th of each month in the amount of
$
effective
. These payments will be applied to my
or
student loan.
3. BANKING INFORMATION
Name of Financial Institution
Branch Address
Bank Number
Transit Number
Account Number
4. AUTHORIZATION
(must be signed)
1.
In this Authorization ‘I’, ‘me’ and ‘my’ refer to each Account-Holder who signs below.
2.
I authorize the Government of Northwest Territories (GNWT) to debit (a ‘Pre-Authorized Debit’) my account indicated above at the Financial
Institution branch indicated above for the purpose of obtaining payment for my NWT Student Loan.
3.
I may revoke this authorization at any time by submitting written notice within one month. I agree that revocation of this authorization does
not terminate any contract for the loan or money that exists between me and the GNWT.
4.
I agree that the Financial Institution is not required to verify that any Pre-Authorized Debit has been drawn in accordance with this
authorization, including the amount, frequency and fulfillment of purpose of any Pre-Authorized Debit.
5.
I agree that the delivery of this authorization to GNWT constitutes delivery by me to the Financial Institution.
6.
I will inform the GNWT, in writing, of any change in the Account Information provided in this authorization at least five (5) working days prior
to the next due date of the Pre-Authorized Debit above.
7.
I warrant that all persons whose signatures are required to sign on the Account have signed this authorization.
This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP), Section 40.(a) and (c)(i)
and the Student Financial Assistance Act and Regulations. The information will be used to determine my eligibility for the Northern Bonus and for
the general administration and enforcement of this program. The privacy provisions of ATIPP protect my information.
Personal information is defined under ATIPP, Section 2. All applicants have the right to examine and request correction of his or her records and to
request a review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact the Manager,
Divisional Financial Services, Income Security Programs Division, Department of Education, Culture and Employment, Box 1320, Yellowknife, NT,
X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
X
Account Holder's Name - Print Name
Account Holder’s Signature
Date - YY/MM/DD
PAGE 1 OF 1
NWT9005/0617