Unclaimed Funds Claim Form—Debtor


Estate name or estate number: Form Field - line
(Name or number appearing in the Unclaimed Dividends Database)

Debtor Information

Name: Space to insert name
Current address: Space to insert current address
City: Space to insert city
Province: Space to insert province  Postal code: Space to insert postal code
Phone: Space to insert phone number ext. Space to insert extension (daytime) Space to insert evening phone number (evening)
Email: Space to insert email address

Banking Information

Direct deposit is the only method available for payments issued after January 1, 2015. Therefore, to receive a payment, provide the following information:

Name of financial institution: Space to insert name of financial institution
Address of financial institution: Space to insert address of financial institution
Financial institution no. (3 digits): Space to insert financial institution number 3 digits  Branch transit no. (5 digits): Space to insert Branch transit no. 5 digits
Name(s) of account holder(s): Space to insert name(s) of account holder(s)
Bank account no.: Space to insert Bank account number
SWIFT code (international payments only): Space to insert SWIFT code (international payments only)
IBAN no. (international payments only): Space to insert IBAN number (international payments only)

A void cheque OR a copy of a blank cheque must be attached to this form.

Consent

I, the undersigned, consent to the Receiver General for Canada issuing my payments as indicated above, by direct deposit, to my bank account. I, the undersigned, have read the Privacy Notice and consent to the collection, use and disclosure of my personal information as outlined in the notice. To ensure prompt payment(s), I will notify the Receiver General for Canada of any changes to my banking information. I, the undersigned, confirm that all information provided above is correct.

Privacy Notice
Your personal information is collected pursuant to the Financial Administration Act, ss. 17(1) and 35(2). The information is used and disclosed to the relevant federal program(s) and to your financial institution for direct deposit purposes. Direct deposit payments cannot be made without providing the information requested on this form. Personal information is protected in accordance with the provisions of the Privacy Act. Under the Act, individuals and businesses have a right to request access to and correct their personal information, if erroneous or incomplete. Personal information collected from this form is stored in the following Standard Personal Information Bank—IC-PSU-931 (Accounts Payable). For questions or comments regarding this privacy notice or for additional information about the administration of the Privacy Act at Industry Canada, please communicate with the Information and Privacy Rights Administration office at 613-952-2088. For more information on privacy issues and the Privacy Act in general, please consult with the Office of the Privacy Commissioner at 1-800-282-1376.

 

Signature of applicant: Space to insert signature of applicant
Name: Space to insert name
Date (yyyy-mm-dd): Space to insert date (year-month-day)

Mailing the form

Forward the completed form and affidavit to:

Office of the Superintendent of Bankruptcy
Financial Services
Heritage Place
155 Queen Street, 4th Floor
Ottawa ON K1A 0H5

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