Protected B / Prot - PDF document

Protected B (when completed) CUR MON - FM - 0 22 - E 2019 - 1 1 Page 1 of 4 Canadian Bank Note Redemption Claim FormGeneral Instructions This claim form is for contaminated or mutilated Canadian bank notes, or forCanadianbank notes that willno longerbelegal tender. Coinswill not be accepted, nor If submitting a claim on their own behalf, they must complete Sections A2, B, C and F. Claims for contaminated or mutilated bank If submitting a claim on behalf of a client, they must complete Sections A1, A2, B, C and F. Claims over $1,000 require a client signaturein Section F, and confirmation that proof of identification has been verified. See Section E for acceptable forms of proof of identification. Claims for contaminated or mutilated bank notes must also include Protected B (when completed) CUR MON - FM - 0 22 - E 2019 - 1 1 Page 2 of 4 Mailing and Packaging Requirements Bank notes are sent at the Claimant’s own risk, so please make sure you take appropriate measures to insure against loss or theft.It is not possible to deliver bank notes in person to the Bank of Canada. For NonLegal TenderBankNotesPut the bank notes into an envelope or package.Send them by regular or registered mail, or by courier, to:Bank of CanadaBank Note Redemption Service234 Wellington StreetOttawa, ON, K1A 0G9 For Mutilated or ContaminatedBankNotesIt is the Claimant’s responsibility to ensure that any mutilated or contaminated bank notes sent to the Bank of Canada for evaluation are packaged in accordance with the relevant legal requirements pertaining to the transportation of contaminated/dangerousgoods. Please refer to http://www.tc.gc.ca/tdg for further information. Subject to any legal requirements referred to above, put the banknotes in a sealable, leakproof bag. For contaminated bank notes, clearly label the bag “contaminated” and describethe nature of the contaminant if it is knownPlease make sure the bag containing the bank notes is clear so the contentof the bag are evident.If the bank note is likely to fall apart, pack it carefully in packing material such as bubble wrap, and place it in a clear, secure bag or container.Place the bagged bank notes, along with the form, into anopaqueenvelope or wrap them into a package. Please do not put yourclaim formin with the contaminated bank notes, and do not mix contaminatednotes with other bank notes you are sending.Send them by regular or registered mail, or by courier, to:Bank of CanadaBank Note Redemption Service234 Wellington StreetOttawa, ON, K1A 0G9 Protected B (when completed) CUR MON - FM - 0 22 - E 2019 - 1 1 Page 3 of 4 adian Bank NoteRedemptionClaim Form(Please print in block letters) SECTION A - CLAIMANT DETAILS 1. If you are an individual / c ompany 2. If you are a f inancial i nstitution (FI) / armoured car c arrier (ACC) Company name (if applicable) Organization name Contact name Surname Address City Province Given n ame(s) Postal codeCountry Address Transit number (if applicable) Telephone number City Province FI/ACC representa tive signature Email address Postal code Country OR CLAIMS ON BEHALF OF A CLIENT:1-Fill out section A1 with client information.2-For claims over $1,000: check the boxes below to confirm that proof of identification was verified and that a client signature has been provided in Section F. r潯ff identifi捡ti潮 verified ig湡t畲e o扴ai湥搠from⁴桥 䍬aima湴 Telep桯n e† Telep桯ne 睯rk
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浡nda瑯ry) SE䍔䥏N⁂ D䥒E䍔 DEPOS䥔⁉NF佒MAT䥏N 剥imbursem敮t,⁩映any, will⁢e⁤eposit敤 瑨e 扡湫 accou湴⁰rovi摥搠i渠t桩s⁳ection 䙩nanc楡氠 i湳titutio渠湡me††††††⁁d摲ess†† 偯獴a氠code Name(s)f a捣ount⁨潬der(s) S畲湡me †† † 䝩ve渠湡me(s) /⁓urna浥 䝩ve渠湡me(s) Tra湳itum扥r 湳tit畴io渠number Acco畮t n畭扥r (i湣l畤i湧 theₓ0”⁩f⁡ppli捡ble) Ba湫⁩de湴ifier⁣o摥 swift畭ber A浥rican⁢an欠accoun琠nu浢er (US bank)* In ternational bank account number * (Outside of Canada - US) *Please ensure the bank account can receive transactions in Canadian dollars. SECTION C - BANK NOTE DETAILS Denomination and number of bank notes (estimated) Value (estimated) Denomination and number of bank notes (estimated) Value (estimated) x x x $50 x x x x $1,000 x Other Canadian b a nk n otes: $ x Total number of bank notes : Total value: Protected B (when completed) CUR MON - FM - 0 22 - E 2019 - 1 1 Page 4 of 4 SECTION D - For CONTAMINAT ED and / or MUTILATED BANK NOTES ONLY How were the bank notes acquired and how long have they been in your possession? Were the bank notescontaminated or mutilated while in your possession? Yes†† No 䑥scri扥⁩渠摥tail⁨ow⁴he⁣o湴ami湡tion or畴ilatio渠to⁴he⁢a湫otes occ畲re搠a湤⁤escri扥⁴桥at畲ef the co湴ami湡tion or 浵瑩la瑩on. Co湳畬t⁴桥 Policy on theRedemption of Contaminated orMutilated Canadian Bank Notes for more information. SECTION E - CLAIMS SUBMITTED OVER $1,000 The Bank of Canada requires Claimants to provide additional information including the following documentation for claims subm itted over $1,000. Failure to submit the supporting documentation will result in theclaim being delayed and/or rejected. copy of proof of identification and 1 copy of proof of residence Proof of Identification Valid passport; residence card; photocard driving licenceealth ard is not considered a valid proof of identification. Proof of Residence Employment pay stub; utility bill (hydro, cable, telephone, gas, etc.)dated within the last sixmonthsroperty tax bill; inancial nstitutionor redit nion ccount statement SECTION F - TERMS AND CONDITIONS In submitting this form and in consideration of the processing and possible settlement of a claim for the re demption of bank notes that will no longer be legal tenderor forcontaminated or mutilated bank notes (“the Claim”) by the Bank of Canada, the Claimant agrees as follows: All claims sent by mail are at the Claimant’s risk. The Bank of Canada, its directors, officers, employees, or other representatives shall not beliable for any costs related to the Claim, for any damage to the bank note(s) that may occur during processing or for any bank note(s) lostwhile in transit.The Claimant acknowledges that the nature of Internet communications is inherently open despite whatever security measures are adoptedand agrees that the Bank may nonetheless use electronic mail or other forms of electronic communication betweentheClaimant and the Bank for the purposes of processinga claim.The Claimant will provide all such information, including personal informationthat, the Bank of Canada may require to process the Claim andconsents to the collection, use and, where required for such purposes as the Bank may in its sole discretion determine, disclosure of suchinformation.TheClaimant further acknowledges that this information is subject to such laws as may apply to the Bank’s activities, includingthe Access to Information Act andPrivacy Act. Questions concerning the application of the Privacy Actmay be directed to: Bank ofCanada’s Access to Information and Privacy Office at -3059or by email atATIP-AIPRP@bankofcanada.caThe Claimant represents and warrants that information provided to the Bank of Canada is true and complete and that the Claimant is therightful owner of the bank notes.The Claimant agrees to indemnify and hold harmless the Bank of Canada, its directors, officers, employees, and other representatives fromany and all loss, damage, liability, cost, penalty or any other expense of whatever nature arising out of any act or omissiondirectly orindirectly relating to this Claim.The Claimant will be responsible for bank account direct deposit fees incurred to process the Claim.The Bank of Canada, in its sole discretion and without prior notice, may disclose any information provided in connection withany claim tothird parties including but not limited to, law enforcement agencies and the Financial Transactions and Reports Analysis Centre of Canada.For contaminated and mutilated bank notes, the Bank of Canada may:a.Request that a Claimant cleanse the bank notes to the Bank’s satisfaction prior to the assessment ofits Claim;Refuse to settle a claim in circumstances it considers suspicious; c. Retain and/or destroy bank notes tendered in any claim that is refused. Signature of the Claimant or the Client (if FI submitting on behalf of a client) Date or additional information please contact 1 800 3031282 or email info@bankofcanada.ca Clear All Print 4 4 4 4