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Get Desjardins 02728A 2013

Ent Policy or group or contract no. City Telephone no. Postal code Province ( ) - I hereby authorize Desjardins Financial Security Life Assurance Company to deposit my benefit payment, through the DIRECT DEPOSIT system, into account at the financial institution indicated below: NAME AND ADDRESS OF FINANCIAL INSTITUTION Institution number: Transit/Branch number: Account number: (Please include a specimen cheque marked “VOID”) Any credit entered in my account in accordance with this aut.

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