Wire Transfer Request Form

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WIRE TRANSFER REQUEST FORM
SECTION A - CUSTOMER INFORMATION
Method of Request: ____ In person
____ Fax
CUSTOMER NAME:
Account#
ADDRESS
City
State/Country
Postal Code
PURPOSE OF WIRE:
Date
Time Rec'd
Contact Phone Number
SECTION B - INTERMEDIATE BANK INFORMATION (if applicable)
Intermediate Bank Name:
ABA Number/S.W.I.F.T. Code:
City
State/Country
SECTION C - BENEFICIARY BANK INFORMATION
Name of Bank Receiving Funds:
ABA Number/S.W.I.F.T. Code:
Account Number(if applicable):
City
State/Country
SECTION D - BENEFICIARY INFORMATION
Beneficiary Name:
D.O.B. :
Account Number:
Address
City
State/Country
Postal Code
Additional Instructions (Optional)
SECTION E - INTERNAL VERIFICATION (Initial to Verify)
Available Funds Verified By:
Debit Memo Posted By:
Call Back Contact:
Phone Number:
PIN Verified By:
Accounting Use Only
Wire Input By:
Wire Verified By:
SECTION F - CUSTOMER AGREEMENT
BY SIGNING BELOW, I HEREBY AUTHORIZE UNIVERSITY BANK TO SEND THE WIRE STATED ABOVE BY DEBITING MY ACCOUNT HERE AT THE BANK. I UNDERSTAND
THAT UNIVERSITY BANK IS NOT RESPONSIBLE FOR ANY ERRORS OR OMISSIONS OF ANY KIND OF OTHER FINANCIAL INSTITUTIONS. I ALSO AGREE TO PAY THE
FEES STATED BELOW.
INCONSISTENCIES BETWEEN NAME AND ACCOUNT NUMBER: IF YOU GIVE UNIVERSITY BANK A FUNDS TRANSFER ORDER WHICH IDENTIFIES THE BENEFICIARY BY
BOTH NAME AND IDENTIFYING OR ACCOUNT NUMBER, PAYMENT MAY BE MADE BY THE RECEIVING INSTITUTION ON THE BASIS OF THE IDENTIFYING ACCOUNT
NUMBER, EVEN IF THE NUMBER IDENTIFIES A PERSON DIFFERENT THAN THE NAMED BENEFICIARY. THIS MEANS THAT YOU WILL BE RESPONSIBLE TO THE BANK IF
THE FUNDS TRANSFER IS COMPLETED ON THE BASIS OF THE IDENTIFICATION NUMBER YOU PROVIDED. IF YOU GIVE UNIVERSITY BANK A FUNDS TRANSFER
WHICH IDENTIFIES THE INTERMEDIARY OR BENEFICIARY'S FINANCIAL INSTITUTION BY BOTH NAME AND AN IDENTIFYING NUMBER, A RECEIVING INSTITUTION MAY
RELY ON THE NUMBER AS PROPER IDENTIFICATION EVEN IF IT IDENTIFIES A DIFFERENT ENTITY THAN THE NAMED INSTITUTION. THIS MEANS THAT YOU WILL BE
RESPONSIBLE FOR ANY LOSS OR EXPENSES INCURRED BY A RECEIVING INSTITUTION WHICH EXECUTES OR ATTEMPTS TO EXECUTE THE PAYMENT ORDER IN
RELIANCE ON THE IDENTIFYING NUMBER YOU PROVIDED.
WIRE AMOUNT
FEE AMOUNT:
Authorized Customer Signature:
Receiving Employee Signature
Supervisor Signature
Wire Forms.XLS
(If Wire exceeds receiving employee's approval limit)

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