Wire Transfer Request Form

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Date to be Sent: ________________________________
Member Number: _________________________
Note: All information is required. Wiring instructions must be obtained from the receiving financial institution by the beneficiary
(recipient) of the wire. Incorrect information can result in delays in wire processing and/or loss of funds. FIFCU is not liable for
any losses suffered due to incorrect information provided. The cut off time for wire processing is 12:00 PM PST. A service charge
will be assessed - See Schedule of fees.
1. RECEIVING FINANCIAL INSTITUTION’S INFORMATION -
Receiving Routing Number:_________________
Financial Institution Name:___________________________________
$ Amount: ______________________________
Written Amount:___________________________________________
(Numeric)
2.
SENDER’S/MEMBER INFORMATION
(Originator) -
Member Name:_________________________________ Debit Account Number______________________________________
Member Address:__________________________________________________________________________________________
Phone Number:________-_________-___________
Driver’s License/ID Number:__________________________________
Email Address:________________________________________________________________
INTERMEDIARY BANK INFORMATION
3.
(Complete only if using a correspondent or middle bank) -
Financial Institution Name: ____________________________________
Account ___________________________________
Address: _________________________________________________________________________________________________
4. BENEFICIARY INFORMATION (Recipient) -
Name_________________________________________________
Account __________________________________
Address:_________________________________________________________________________________________________
If Address is the same as section 2, please check the box 
5. MISCELLANEOUS/REFERENCE INFORMATION -
6. PURPOSE OF WIRE -
*Please attach wiring instructions for Title or Escrow Wires.
By signing below, I certify that the information provided is correct and I agree with the terms set forth.
Member’s Signature_______________________________________ Date________________________
(A callback must be done on ALL wires unless a Credit Union Representative has witnessed and verified the actual signature)
CREDIT UNION USE ONLY
Supervisor Signature: __________________________________ Date: _______________________
Received By: ___________ Date:____________ Person  Fax  Phone Email
Service Charge:  Yes  No
CMF Real Estate Dept. Accounting Loan Dept.  Management  Marketing  Other____________
In-Person/Branch #: _______
Callback/Who performed callback? _________________
Verification:
Please indicate Verification used:_________________________________________________________________________
Wire Entry and Verification:
Entered by: __________ Journal by:________ OFAC by:________ Verified/Sent By:____________
07/21/2016

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