Electronic Warrant - Wire Transfer Form
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1TEMPLATE FORM
CB$ ELECTRONIC WARRANT – WIRE TRANSFER
Revised 02/2016
(To be used to establish a template for a repetitive wire transfer via CB$)
To:
From:
(
):
Agency Name and Address
Department of State Treasurer
Date: _ _________________
Banking Operations Section
Email:
Pursuant to the State Treasurer’s established procedures for the use of Electronic Warrants, this is to request the establishment
(or deletion/change) of a repetitive template number. The requested preauthorized payment meets the established criteria, which are:
1) repetitive in nature; 2) time sensitive; 3) are to be made in same day funds; and 4) are sizable amounts.
:
TYPE OF REQUEST
____ Add
____ Delete
____ Change (If Delete or Change, current Template No. ________________)
DEBIT INFORMATION (Source Account):
Disb./ STIF Acct. Number: __ - __ __ __ - __ __ __
Account Name: _____________________________________________
TYPE OF PAYMENT (Product Code):
___ FT31 – Payroll Funding
___ FT33 – Debt Service Wire Transfer
_X_ FT32 - Federal Tax Funding
___ FT3W – Withdrawal from STIF ___ FT3K – 401K Payments
___ FT3D – Deferred Comp Payments
___ FT3E – EFT Funding NCAS ____ FT3P – EFT Funding CPS
___ FT39 – Other: ____________________
PAYMENT INSTRUCTIONS:
Wells Fargo Bank
San Francisco, CA
121000248
Payee Bank Name:
City/State:
ABA #:
North Carolina Department of State Treasurer
2062601258255
Payee Name (Beneficiary):
Acct#:
Payment Details (OBI):______________________________________________________________________________________
JUSTIFICATION FOR REQUEST:
REQUEST / PREAUTHORIZATION SUBMITTED BY:
Agency Name: ________________________________________________
CB$ Agency ID: __________
(XXXNNNN Characters)
Printed Name & Title: ________________________________________________
Signature: ___________________________________
(Must be on signature card)
Phone Number: __________________________
Fax Number: ________________________
FOR STATE TREASURER’S USE ONLY (Complete If Approved):
Template No. Assigned: ________________
____ Template setup/modified on CB$
____
Template setup/modified on Wells Fargo
____ Signature card verified
By: ___________________________________________
Date: ________________
Setup/Modification Reviewed By: ________________________________ Date: ________________
If request is approved by State Treasurer, a copy of this form will be returned to the Agency’s Chief Fiscal Officer.
All agency CB$ users granted the Funds Transfer role, and mapped to the associated account, will be able to initiate/authorize electronic warrants for the template.
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