Wire Transfer Form printable pdf download

Wire Transfer Form

WIRE TRANSFER FORM

CALL BACK PHONE #____________

International Wire Fee:

25.00

CHECKED WITH OFAC/FINCEN____

Domestic Wire Fee:

15.00

Our Customer Info

Branch #:

Debit Account #:

Customer Name:

Customer Address:

City/ST

Zip

Bank Info

9 DIGITS REQUIRED

ABA#:

Bank Name:

Bank Address:

City/ST

Zip

Amount:

Beneficiary Info

Acct Number:

Name:

Address:

City/ST

Zip

Further Credit Info.

Account Number:

Name

Address

City/ST

Zip

ORIGINATOR AUTHORIZATION AND ACKNOWLEDGEMENT OF DISCLAIMER

I hereby authorize First State Bank (Bank) to execute the above wire transfer order provided sufficient collected funds are

available on the wire date. I agree that once this wire transfer is sent, this wire transfer order is irrevocable, and that Bank's

sole obligation herein is the exercise of ordinary care. I hold Bank harmless for any loss or delay resulting from third party

involvement in processing this wire transfer.

DATE OF WIRE TRANSFER ORDER

AUTHORIZING SIGNATURE OF ORIGINATOR

*****Request taken by:

Officer Approval Signature:

For Wire Transfer Dept Use

Entered by

$.01 - $50,000.00

Employee

$50,000.01 - $250,000.00

1 VP or higher

Verified by

$250,000.01 & up

2 VP's or higher

Exception to policy Yes ___ No ____

Approved by _____________________________

Wire Transfer Form

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