Fillable International Outgoing Wire Transfer Request Form (Page 2 of 2) in pdf

CURRENCY INFORMATION

Name of Receiving Country: ___________________________________________________________________

Tell us the amount and the currency type that you want to send. Check Only One.

(If you don’t know the currency type, choose the U.S. Dollars option and we will send USD)

Send ________________ in USD to be delivered in U.S. Dollars

Amount

Send ________________ in USD to be delivered in ____________________________

Amount

Type of Currency (i.e. Euros, Rupees, etc.)

Send ________________ in ____________________________ to be delivered in that currency

Amount

Type of Currency (i.e. Euros, Rupees, etc.)

PURPOSE OF PAYMENT

Please note that this information is not required, however, not providing this information may delay the crediting of

the beneficiary account or cause the wire transfer to be returned to Meriwest unpaid. The information required by

each country varies. Please refer to the Beneficiary or Beneficiary Bank to confirm the information that may be

required.

Relationship between Sender and Beneficiary (i.e., family member, self, customer & seller, employer &

employee or consultant):

__________________________________________________________________________________________

Purpose of Payment (i.e., living expenses, rent, purchase of property, goods or services [you may wish to

specify details of purchase], payment for work completed):

__________________________________________________________________________________________

Additional Information for Beneficiary or Beneficiary Bank (i.e., invoice or escrow number, RUT, account type)

__________________________________________________________________________________________

WIRE TRANSFER INFORMATION

In this Outgoing Wire Transfer request Form (“Form”), “Meriwest” shall mean Meriwest Credit Union; and “Sender” shall mean the undersigned

Meriwest account holder, authorized signer, or attorney-in-fact having authority over the Meriwest member account from which the funds are

to be wired.

Sender understands and agrees that all wire transfer requests received by any means are subject to verification and

authentication pursuant to Meriwest’s security procedures, prior to acceptance and processing. Sender is responsible for the accuracy of all

information provided on this Form, including the beneficiary’s account number, and understands and agrees that Meriwest shall not be

responsible for misdirected funds resulting from any incorrect beneficiary account number provided. Except as prohibited by law, Sender

hereby releases Meriwest from all liability from any loss unless the loss arises out of Meriwest’s failure to exercise ordinary care, failure to act

in good faith, or failure to act in accordance with Sender’s instructions pursuant to this Form. Meriwest shall not be liable for any refund to

Sender for cancelled wire transfer requests until Meriwest receives confirmation of the returned funds, unless the wire transfer request

qualifies as a consumer “remittance transfer” as defined by the CFPB’s Regulation E and the cancellation request is received within 30

minutes after Sender makes payment for the transfer. Wire transfer requests initiated by a business Sender do not qualify as a “remittance

transfer” and are excluded from the 30 minute cancellation period.

By signing below, Sender represents and warrants that all information provided in this Form is accurate and complete, agrees to the

terms and conditions of this Form, and authorizes Meriwest to debit the above identified Meriwest account number for the U.S.

Dollar amount or U.S. Dollar amount equivalent of the foreign currency amount, plus applicable fees and taxes. Sender further

acknowledges and agrees that wire transfers are subject to the terms and conditions of the Funds Transfer Agreement signed by

Sender, the Credit Union’s Account Disclosure and Deposit Agreement, and Fee Schedule.

Sender’s Signature: _________________________________________

Date: ___________________

For MCU Financial Center use only:

Request received in person:

Yes Fee Disclosed:

Yes

Processing Date Disclosed:

Yes

Pre-Disclosure Provided to Sender?

Yes

Proof of Payment Provided to Sender?

Yes

Valid Identification Type______________________________ ID Number: _______________________ Expiration Date: _________

Signature Verified by: _____________________________________________________________ Operator Number: ___________

Meriwest Credit Union Revised 08/08/17

Page 2 of 2

International Outgoing Wire Transfer Request Form Page 2

Related Articles

Related forms

Related Categories