Wire Transfer Request Form

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Attachment 43
WIRE TRANSFER REQUEST FORM
Form must be typed. Forms with hand-written information and/or missing required fields will be
returned to the Fiscal Administrator. Refer to Policy 2.706.
PAYEE INFORMATION
Beneficiary (name on bank account)
Address
City, State or Country
Bank Account Number
WIRE PAYMENT INFORMATION
DOMESTIC WIRE
U.S. Dollar Amount
$
Bank Name
Bank Address
Bank ABA Number (9-digit)
INTERNATIONAL WIRE
Amount $
U.S. Dollar*
*The following information is required when wiring U.S. Dollars to a foreign country
U.S. Correspondent Bank Name
U.S. Correspondent Bank ABA No.
$
Foreign Currency Type
Amount
OR USD Equivalent**
Bank Name
Bank Address
Country
Bank SWIFT Code
**Enter the USD amount if the vendor has invoiced in USD but will accept payment in a foreign currency.
Remittance/Reference Information (e.g., PO Number, Invoice Number, etc.)
PROJECT INFORMATION
Charge the Bank Fee to
Project Number
Budget Category
Wire confirmation will be faxed to the Fiscal Administrator
FA Name
FA Fax Number

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