Fillable Hanscom Federal Credit Union Domestic Wire Transfer Form printable pdf download

HANSCOM FEDERAL CREDIT UNION

DOMESTIC WIRE TRANSFER FORM

Members/Joint Owners are to complete boxes 1 through 3 only.

(Box 1)

Date

Member Account #

Money Market Other

Savings

Checking

Member Name

Daytime Telephone #

Social Security #

Date of Birth

Member Address

City/State/Zip

DOMESTIC WIRE INFORMATION – Please print clearly

(Box 2)

Domestic Wires in excess of $50,000.00 – a copy of a valid US Drivers’ License or Passport MUST be included with this form.

US Currency Amount Wired $

Wire Charge $20.00

US Bank/Credit Union Name

ABA #

    -     - 

Bank/Credit Union Address

City/State/Zip

Intermediary US Bank/Credit Union Name

(If Applicable)

    -     - 

Intermediary US Bank/Credit Union ABA #

(If Applicable)

Intermediary US Bank/Credit Union Additional Information

(If Applicable)

Beneficiary Name

Beneficiary Account #

Misc. Wire Information

Beneficiary Address

City/State/Zip

(Box 3)

I understand that Hanscom Federal Credit Union (HFCU) is acting strictly as an agent and will act only on the instructions that I have provided. In the

event that the information provided is incomplete or incorrect, I release HFCU from any liability that may result. The payee or any Financial Institution (FI)

may be identified by name, account number, or ABA #. HFCU (and other institutions) may rely on the account or other identifying number as the proper

identification, even if it identifies a different party or institution. Regulation J governs a wire transfer cleared through the Federal Reserve. I authorize

HFCU to transfer funds as described herein and debit my account in the amount transferred, plus applicable charges. I understand that should I request

a wire by fax, telephone or by secure email, the wire will be verified by a call-back from a Credit Union employee to me using a telephone number

currently on file at HFCU. This call-back may require me to send a secure email verifying the authenticity of the telephone or fax request.

 Member/Joint Owner Signature

Date

Verifying Information to be completed by HFCU Employee – Entire section must be completed

Print Employee Name completing form

Operator #

Extension #

Branch Office

Employee Signature completing form

Verification of Member – Type of ID

ID #