SC ISP-1401 (2017-11-27) E 1 / 3 Disponible en français
PROTECTED B (when completed)
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
Declaration of Attendance at School or University
Section A - To be completed by student after the start of first day of class
1. Contributor's Social
Insurance Number
Contributor's given name and initial Family name
2. Your Social Insurance
Number
Preferred language
English
French
Your given name and initial Family name
3. Your home address
Home address (No., Street, Apt. No., RR) City, town or village
Province or territory Country Postal code
4. Mailing address (If different from home address)
Mailing address (No., Street, Apt. No., PO Box, RR) City, town or village
Province or territory Country Postal code
5A. Student ID number 5B. Name of school, university, college, training centre, etc.
6A. Type of enrollment (if "Evening" or "Other", please
provide an explanation in question 8)
Full Time Evening Other
6B. Number of
courses per term
6C. Enrolled in (specify course, grade or program)
7A. Number of hours you are required to attend for
course, grade or program.
Hours per week:
7B. When did your current
attendance begin?
YYYY-MM-DD
7C. When will your current
attendance end?
YYYY-MM-DD
8. Give duration and reasons for any absence(s) during your current and past academic year plus any additional explanation with
reference to question 6A if "Evening" or "Other" was selected.
9. Have you applied for or are you receiving a Canada Pension Plan
benefit as a result of the disability or death of a contributor not
identified in question 1?
Yes
No
Social Insurance Number of that Contributor
SC ISP-1401 (2017-11-27) E 2 / 3
PROTECTED B (when completed)Social Insurance Number:
10. Payment Information
Direct deposit in Canada: Complete the boxes below with your banking information.
Branch number (5 digits) Institution number (3 digits) Account number (maximum of 12 digits)
Name(s) on the account Telephone number of your financial institution
Sharing your direct deposit information with the Canada Revenue Agency
For Employment and Social Development Canada (ESDC) and the Canada Revenue Agency (CRA) to share your personal and
direct deposit information, your consent is required.
By selecting "I agree", you agree with these two statements:
- I consent to ESDC sharing with the CRA my direct deposit information entered on this form for any payments I may
receive from the CRA.
- I consent to ESDC sharing with the CRA my Social Insurance Number, last name, and date of birth so that the CRA can
identify me correctly.
If you select "I do not agree", your information will not be shared.
I agree I do not agree
Direct deposit outside Canada:
For direct deposit outside Canada, please contact us at 1-800-277-9914 from the United States and at 613-957-1954 from all
other countries (collect calls accepted). The form and a list of countries where direct deposit service...
