HR3641 (18/03/2
6)
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Bank Profile and Consent
Security Classification: MEDIUM SENSITIVITY
The personal information collected on this form is requested under the authority of and will be used for the purpose of administering the Employment and Assistance Act and the Employment and
Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any
questions about this information should be directed to your local Employment and Income Assistance office.
Last Name First Name Middle Name(s) SR Number
Bank Name
Consent attached, or client sign here:
I give permission for the financial institution named above to provide the information requested on this form to the
Ministry of Social Development and Poverty Reduction:
Signature Date Signed
Please provide details below for all accounts (copy form or use back of page if insufficent space) and provide a
transaction statement for the most recent
period. (For closed accounts, please provide a statement
for the period prior to date of closing).
Please provide the completed form to the client
Please return the completed via mail or fax to my attention:
Name
Address
Fax
For Bank/Financial Institution use only
Please complete an "All Branch Search" and either complete this form, including bank stamp and signature,
or supply a printout providing the requested information.
Please check below to indicate all accounts on which the the above-named individual is a primary account holder or a co-
account holder, including open accounts and accounts closed within the last six months .
The above-named individual has no accounts (open or closed within past six months) at this financial institution.
Chequing Account US $ or International Acct RRSP, RDSP, or RESP
Annuities or Other Investments Savings or TFSA Acct Business Accounts
GICs, Term Deposits, RRIFs Loans, Mortgages, Lines of Credit Youth or Student Acct
Credit Cards Mutual Funds, Bonds Trust Accounts
Other
Account Type Status
Open Closed
Date Closed Account # Joint
Yes No
Value Balance
Bank Stamp
Date
Financial Institution Name
Address
Contact Name
Signature
