Funds Transfer Request
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1
2OUTGOING WIRE FUNDS TRANSFER REQUEST
WIRE AMOUNT/SOURCE
SELECT ONE
AMOUNT TO WIRE *
*
WIRE DESTINATION/CURRENCY TYPE *
REPETITIVE WIRE ID #
complete only those fields w ith an
DOMESTIC WIRE
(U.S. Dollars)
INTERNATIONAL WIRES: Funds w ill be sent in t he currency
INTERNATIONAL WIRE ____________________
of t he dest inat ion count ry, w hen available; unless ot herw ise
specif ied. If f unds must be sent in USD t o a USD benef iciary
Indicate Currency Type
account , please indicat e by checking t his box:
Provide amount in the “ Currency Type” indicated
FOREIGN CURRENCY EXCHANGE RATE SOURCE
(If Applicable)
ACCOUNT NUMBER / SOURCE OF FUNDS *
If OVER US $25,000 equivalent contact 1-(888) 819-8883 for a rate quote
W/D FROM ACCOUNT #:_________________________________
Rat e Source:
RATE SHEET
FX DESK
CASH
-
Credit ed by Branch t o GL 242830/cc510
FX Rat e: ______________________________________
Value Dat e: ____________________________
Prior Risk Management approval required if over branch limit
$
Quot ed By: ____________________________________ USD Equivalent
: _____________________
CHECK
Credit ed by Branch t o GL 242830/cc510
-
(Trader’ s Name)
Prior Risk Management approval required if over branch limit
Ref erence #: ____________________________________________________________________________
ORIGINATOR INFORMATION *
ORIGINATOR’S NAME *
ORIGINATOR’S CONTACT PHONE NUMBER *
PAYMENT INSTRUCTIONS
WIRE TO
CREDIT TO
BENEFICIARY BANK NAME (BBK)
BENEFICIARY NAME (BNF)
BENEFICIARY BANK ADDRESS (BBK ADDR)
BENEFICIARY ACCOUNT NUMBER (BNF AC#)
BENEFICIARY ADDRESS (BNF ADDR, PHONE NUMBER)
(If foreign bank address, please include both CITY and COUNTRY information)
BENEFICIARY BANK’S ABA
or SWIFT CODE
(domestic)
(International)
(SWIFT Bank Identifier Code (BIC), International Bank Account # (IBAN), International Sort/Routing/Clearing Code,
\
(If foreign address, please include both CITY and COUNTRY information along w ith beneficiary contact phone number)
Transit, CLABE – if applicable)
If applicable - INTERMEDIARY BANK INFORMATION (IBK)
MESSAGE OR REFERENCE – ORIGINATOR TO BENEFICIARY INFO* (OBI)
(routing / ABA,SWIFT / BIC)
*
ORIGINATOR’S AUTHORIZATION
By Signing below, I agree to the terms accompanying this form.*
(Originat or’ s Signat ure)
(Dat e)
(Originat or’ s Signat ure)
(Dat e)
BANK USE
ORIGINATOR’S ID
REQUEST TYPE
NO FTA Form – Approval By (Printed Name)
*
*
*
Driver’s License
Passport
Green Card
In Person
Letter
Phone
FAX
E-Mail
(Attached)
___________________________________________
Branch Manager or Risk & Ops. Employee.Name
Other ___________________________________
* Phone / FAX / E-Mail Requests - 1.) MUST adhere to Bank callback
$
requirements (complete Callback Results section below ); and 2.) MUST
__________________
FEE AMOUNT:
Issued By: _________________________________
have a Funds Transfer Designation and Authorization (FTA) on file. If
FX Wires Only - Optional Other Fee Allocation
NO FTA is on f ile, the request must be approved by the Branch Manager
Serial Number: ______________________________
BEN
OUR
[def ault ]
(up to $200,000) OR Risk & Operations (if over $200,000)!
CALLBACK RESULT
Callback / FTA Verified By - Employee (Print Name / Initials) Callback To - Customer (Print Name)
Callback To - Phone Number
No Callback
(FTA Waiver)
Callback Completed w /Auth Cust.
Employee w ho completed callback or verified FTA w aiver
Authorized Customer that confirmed w ire
Phone number used for callback
BRANCH/DEPARTMENT USE ONLY
WIRE DEPARTMENT USE ONLY
INSTRUCTIONS ACCEPTED BY
Dept./Branch Name or #
Wire Input By
(Print Name & Signature)
(Initials)
Time Accepted
Date Accepted
Test Key Reference Number
Test Key Result Number
Wire Verified By
(Initials)
A.M.
P.M.
SUPERVISOR/AUTHORIZED EMPLOYEE APPROVAL
nd
Callback Verification By
(2
signature required if over limit)
(Initials)
Verification of request form, customer ID, payment method, request type and customer’ s authority as an authorized account signer.
Callback Verification With
(Printed Name)
__
__________________
______________________________________
________________
Approval Signature
“ Over Limit” Approval Signature (as required by policy)
Date Wire Executed
______________________________________________
_________________________________________________
Printed Name REQUIRED
Printed Name REQUIRED
WIRE2014.DOC / Rev. 11-2014
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