Wire Transfer Request Form

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Wire Transfer Request Form
Date
SENDER/ORIGINATOR INFORMATION
Name 
Day Phone Number
Address 
Wire Amount
City, State, Zip
Member Number/Acct Type 
Instructions from Sender 
BENEFICIARY/RECIPIENT INFORMATION
Name
Address 
City, State, Zip
Account Number
Special Identifier of Beneficiary (ie: SSN, TIN, DL#) 
BENEFICIARY/RECIPIENT FINANCIAL INSTITUTION
Name of Financial Institution 
Address  
Cit St t Zi
City, State, Zip
ABA/Transit Routing Number 
Further Credit ‐ Financial Institution
Address 
City, State, Zip
ABA/Transit Routing Number 
You authorize the Credit Union to transfer funds as described herein and debit your account in the amount transferred plus applicable fees
Signature
Date
Credit Union Use Only
Date and Time of Request
Request Taken By 
$
Request 
Taken     In person ______  Phone _____  Fax  _____  Email  _____
‐
 
 
Fee
Processed By
Approved By
Call Back Performed By
 (required on all wire requests not taken in person and equal to or greater than $1K)
Additional Comments
Revised  04.18.2014

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