Direct Deposit Application for Future Distributions

Direct Deposit Application for Future Distributions
Updating Banking Information Request
Applicant Personal Information

Required
1. Name of the Blood Tribe Member*

First NameLast Name
2. Date of Birth*

MonthDayYear
Date
3. Blood Tribe Treaty # (10 digit)*
No Hyphen
4. Email Address*
example@example.com
5. Phone Number*
Please enter a valid phone number.
Dependents
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Proof of Identity - Required

Attach to application copy of photo ID of applicant and dependents. Examples: Indian Status Card, Driver’s License, Passport, Provincial ID, Blood Tribe Membership Card)
Upload Identity Documents here*

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1. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Payment Options - Required

Please note that under no circumstances shall the Blood Tribe, its employees, administrators and representatives be held liable for any direct or indirect, incidental, exemplary or other damages whatsoever resulting from the choice of payment method (including without limiting the generality of the foregoing, providing an account number that is a joint account), or arising from the conduct of a third party whether or not the Blood Tribe has been notified of the possibility of such damages.
Please Check One Box Only*

Direct Deposit (Canadian Accounts only)Mail Out Cheque
Direct Deposit Information

If you chose “Direct Deposit” method of payment please attach either a cheque for your bank account marked “VOID”, or a certificate of personal banking information issued by your financial institution.
Financial Institution - Canadian Accounts only*
for example: Scotia Bank
Financial Institution /Transit Number*
Account Number*
Upload VOID cheque or your Banks Direct Deposit Form here*

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Declaration / Privacy consent
Solemn Declaration:

I solemnly declare that I am a registered member of the Blood Tribe Band, that the identification documents presented are unaltered and are a true likeness of me, that all of the statements made and the information provided in this application, as well as any supporting documents, are true, and I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath.

Authorization:

I, as the recipient entitled to receive payments, authorize Blood Tribe Membership to deposit the payments electronically into the account specified above. I acknowledge that all the banking information provided will be entered in the Blood Tribe Financial System.
Name of the Applicant*

First NameLast Name
Signature of the Applicant*

Clear
Date Signed*

MonthDayYear
Date
Please verify that you are human*
For Office Use Only
Name of the Authorized Signatory

First NameLast Name
Signature of the Authorized Signatory

Clear
Date Signed

MonthDayYear
Date
If more then 5 please enter names below
Should be Empty:

Direct Deposit Application for Future Distributions

Updating Banking Information Request

Applicant Personal Information

Dependents

Proof of Identity - Required

Payment Options - Required

Direct Deposit Information

Declaration / Privacy consent

For Office Use Only