(Please indicate the type of credit card with an "X")
Card security/card verification value code (CVV)
IMM 5620 (01-2012) E FEE PAYMENT FORM - APPLICATION FOR PERMANENT RESIDENCE STEPS TO FOLLOW: 1. Calculate the applicable fee by referring to the fee table below. Citizenship and Immigration Canada Citoyennet et Immigration Canada This form must accompany your application for Permanent Residence under certain programs. Refer to the instruction guide to know if you can use this fee payment form. Please refer to step 3 of your instruction guide for acceptable methods of payment. Applications submitted with incorrect payments will be returned.
PROTECTED WHEN COMPLETED - B 2. Pay by certified cheque, bank draft or money order payable to THE RECEIVER GENERAL FOR CANADA or by Visa, Mastercard or American Express. 3. Include the payment form and the documents specified in the Document Checklist with your application, specific to the class you are applying under.
4. Check the appropriate box to indicate your method of payment: Note: The credit card must be valid for at least nine (9) months from the date of submission of your application. Otherwise your application will be returned. SECTION B - CREDIT CARD PAYMENT AUTHORIZATION I agree to pay the Receiver General for Canada CAD$ on my credit card for fees related to an application for permanent residence. Name of cardholder (please print) Year Month Day FOR OFFICIAL USE ONLY Authorization number SECTION A MASTERCARD VISA AMERICAN EXPRESS Credit card number Expiry date of the card Month Year A three (3) or four (4) digit number usually found on the back or front of the credit card. Note: The amount authorized must be equal to a single fee or a multiple of a single fee. Authorizations for other amounts are incorrect. Principal applicant Each family member age 22 or older Each family member under age 22 who is married or in a common-law relationship Processing Fee Number of persons Amount due $ CAD Each family member under age 22 who is unmarried and not in a common-law relationship $ 550 x $ 550 x $ 550 x $ 550 x $ 150 1 Amount per person Total payment: METHOD OF PAYMENT OPTIONS A combination of more than one method of payment is acceptable. However, payment by each method MUST be equal to a single or a multiple amount per person that you have indicated in Step 1 above. For example: An amount of $550 paid by credit card for the principal applicant, and 2 x $150 paid by a certified cheque for 2 dependents for a total of $850 is acceptable. However, $500 paid by credit card and $350 by certified cheque will not be accepted. Name of payer (if different from the principal applicant) Name of principal applicant (given name(s), surname) Address of payer (if different from the principal applicant) Date Signature of cardholder Credit card (complete section A and B below) Certified cheque, bank draft or money order (enclosed and complete section A below)