Western Union Quick Cash Transfer Agreement Form
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2Patent and Trademark Office Federal Credit Union
Western Union Quick Cash Transfer Agreement
At your request, we can transfer funds (up to $10,000) to you via Western Union QuickCash money transfer
system. You authorize the Credit Union to transfer funds as described herein and debit your account in the
amount transferred. You authorized the Credit Union to have the fee shown drawn out of the same account
from which the wire is done.
Amount (U.S. Dollars) To Be Transferred: $_________________________
1.
2. Account Number: ____________________________
______ Savings
_______Checking
_______ Money Market
_______________________ Other
3. City And State Of Expected Payout Location: _________________________________________________
4. Name of Recipient: ______________________________________________________________________
5. Physical Description (or license number): ____________________________________________________
6. Test Question (used for identification), i.e.: “What is your favorite food?”
______________________________________________________________________________________
7. Test Answer: ___________________________________________________________________________
8. Fee to be charged, $____________________
Domestic Transfers (within the United States): Western Union Fee is $20.00 for transfers under $100.00
and $30.00 for transfers $100.00 and over.
International Transfers: under $500.00 will be charged a total fee of $30.00. For transactions over
$500.00 there is a fee of 2% of principal in addition to the $30.00 fee.
9. Additional Instructions (i.e.: Photo ID is required): ______________________________________________
10. Date: _____________________
Daytime Phone Number: ____________________________________
11. I authorize PTOFCU to debit the funds for the Western Union “Quick Cash” wire from my account.
X _________________________________________________________________
Member’s Authorized Signature
See over for Funds Transfer Agreement and Notice.
_________________________________________________________________________________________
FOR OFFICE USE ONLY
Transfer performed by: ___________________________________________________
Date: __________________
Time: ___________________
Confirmation No.:_____________________________________
Transfer callback by: ____________________________________________________
Date: ____________________
Time: ___________________
Method: ____________________________________________
Transfer confirmed by: ___________________________________________________
Date: ___________________
Time: ____________________
Western Union Employee: _____________________________
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