BSF726 - Electronic Payment Adjustment Form

Part I - Routing Information

Date
File Number

To: Revenue Accounting and Reporting Division
Accounts Receivable Unit
CBSA-ASFC_RAR@cbsa-asfc.gc.ca

Telephone Number
(343) 291-5738
Fax Number
(343) 291-5753

Name
Address
Position
Telephone Number
Fax Number

Part II - Payment Adjustment Details

Bank Authorization Number (BAN)
Adjustment Amount
Date of payment
Client Name
Business Account Number
Reason(s) for electronic payment adjustment
Fax this form to Revenue Accounting and Reporting Division - Accounts Receivable Unit

Part III - Authorization to Process Edi Payment Adjustment (To be completed by CBSA)

The Financial insitution identified above is authorized to process the following debit adjustment to the Receiver General's concentrator account
Date received
Adjustment Amount
Authorization Date
Signature

Part IV - Confirmation of Debit Adjustment (To be completed by Financial Institution)

In accordance with the above-authorization, this is to certify that a debit adjustment has been made to the Receiver General's concentrator account.

Bank Authorization Number (BAN)
Adjustment Amount
Date of Adjustment
Name
Signature

Date modified:

2015-03-11