Czech Republic Direct Deposit Enrollment Form Completion Instructions

• Enrollment Form - HTML Version
• Enrollment Form - PDF Version (.pdf 142Kb)

Introduction

A direct deposit form has been designed to support the capture of key information from pensioner's wishing to enroll on direct deposit in Czech Republic. The following is a step by step procedure developed to guide the pensioner in the proper completion of the form.

Completion Instructions

The Czech Republic enrollment form is divided into three sections. They are :

• Part A - Pensioner Identification Information;
• Part B - Pension Program Identification; and
• Part C - Identification of the Financial Institution.

Part A - Pensioner Identification Information :

Part A provides space for you to identify your name, address and telephone number. The following is a step by step procedure.

Step 1 and 2 :

Enter your surname and given name and initial(s) in the boxes provided. One letter per box. Please use capital letters.

Step 3 :

Enter your address information including the name of the city and country.

Step 4 :

Confirm if the address is new by entering () in yes or no.

Step 5 :

Enter your area code and telephone number in the event that we may need to contact you to seek clarification on the information provided.

You have now completed Part A - Pensioner Identification Information.

Part B - Pension Program Identification :

Part B provides a mechanism for you to specify the payment(s) you want deposited directly into your Czech Republic account. To enroll, check the appropriate box and include one of the following in the space provided : your social insurance number, contract number, file number, pension number, or personal record identifier.

The department responsible for your pension program will use this information to match your entitlement and to issue the requested electronic payment.

[Long description of Part B Image - Program Identification]

Step 1 :

Check off the box(es) for the payment(s) you wish to receive by direct deposit.

Step 2 :

Enter the number associated to each type of payment you wish to receive.

You have now completed Part B - Pension Program Identification.

Part C - Identification of the Financial Institution :

Part C provides specific fields for you to capture your direct deposit account information. The IBAN has a fixed format for each country. Please contact your local financial institution for a better understanding of your IBAN.

[Long description of Part C Image - Identification of the Financial Institution]

Step 1 :

Enter the IBAN number provided by the financial institution which represents a complete identifier, that includes original bank code and account number, plus additional characters to identify the country and special check digits.

AND

Along with the IBAN number, please also include the BIC SWIFT number which is the code that identifies the specific electronic address of the financial institution.

Step 2 :

Enter the name(s) of the account holder(s).

Step 3 :

Enter your financial institution name and address.

Step 4 :

Please obtain the signature of the financial institution official.

Step 5 :

Enter your bank area code and telephone number, in the event that they need to be contacted for clarification on the information provided.

Step 6 :

The beneficiary must sign and date the bottom of the enrollment form. If the individual completing this form is a guardian or a relative acting on behalf of the beneficiary, this enrollment information will not be considered valid without the beneficiary's signature.

Note

For additional information, call 00-800-3671-8290 between the hours of 8 a.m. and 8 p.m., Eastern time.

Provision of the information requested on this form is required to effect direct deposit payments. This personal information will be stored in Personal Information Bank Number PWGSC PPU 085 and is protected under the Privacy Act. Under the Act you have the right to request access to and request correction if erroneous or incomplete. The information is retained for six years after the last administrative action and then destroyed.

The first direct deposit may take approximately three months after receipt of your completed enrollment form.