Authorized Account Information. The outgoing wire transfer pursuant to this request is to be made from the account specified below, hereinafter referred to as “authorized account”. The name and address of the undersigned Originator requesting the outgoing wire transfer in this request is set out below. Wire Amount: $________________ Date: _____________ Time: ___________ Fee Amount: $20 Reg Fee (Circle one) $30 Reg Fee + Fax Fee Total: $________________ Receiving Bank: Wire Transfer ABA#: Physical Address: Beneficiary Name: Beneficiary Account #: Beneficiary Address: *Further Credit Bank:_______________________________ *Account:____________________ Special Instructions: Your Name: Your Physical Address: Purpose of Wire: Your Account # at FLNB: Your Phone Number: Your Cell Phone Number: I agree to the representations, warranties, terms and conditions on page 2 of this agreement. Your Signature: You must have a sufficient COLLECTED Balance in the account to be charged. In order to complete your Wire Transfer Request, you MUST provide the following documents: An accurate, legible, completed Wire Transfer Application. A copy of your Driver’s License. -------------------------------------------------------------------------------------------------------------------------------------------- BANK INFORMATION ONLY – VERIFICATION PROCESS Method of request received: Circle one (Fax), (Email) or (In person) Received by: ____________________________ (Employee name) OFAC Verification (attach Horizon XE printouts): (Employee initials) Beneficiary: ______________ Bank(s): ________________ Horizon XE Sequence Number: __________________________ Signature Verified? Yes / No Attach Completed Call-Back Script Document One-Time Outgoing Wire Transfer Agreement Originator requests First Liberty National Bank (Bank) to make a one-time wire transfer from the authorized account specified to the beneficiary’s deposit account in the beneficiary’s bank specified. Wire transfer request received by 3:30 pm will be processed the same business day. Requests received after 3:30 pm may not be processed until the following business day. Originator agrees to the following security procedures to be taken by the Bank before making the wire transfer in this request: (1) for requests submitted in person at a Bank branch, to verify the identity of the person signing the request and determine if the name of such person on the request is an authorized signer on the account to be debited, (2) if the request is made by fax/email to ...
Authorized Account Information. The outgoing wire transfer pursuant to this request is to be made from the account specified below, hereinafter referred to as “authorized account”. The name and address of the undersigned Originator requesting the outgoing wire transfer in this request is set out below. Date: Amount: Receiving Bank: Wire Transfer ABA#: Physical Address: Beneficiary Name: Beneficiary Account #: Beneficiary Address: Special Instructions: Your Name: Your Physical Address: Your Account # at FLNB: Your Phone Number: Your Cell Phone Number: I agree to the representations, warranties, terms and conditions on page 2 of this agreement. Your Signature: YOU WILL BE CHARGED A $10.00 FAX FEE TO COMPLETE THIS TRANSACTION IN ADDITION TO THE $20.00 WIRE TRANSFER FEE. • You must have a sufficient COLLECTED Balance in the account to be charged. • In order to complete your Wire Transfer Request, you MUST provide the following documents:
Authorized Account Information. The outgoing wire transfer pursuant to this request is to be made from the account specified below, hereinafter referred to as “authorized account”. The name and address of the undersigned Originator requesting the outgoing wire transfer in this request is set out below. Wire Amount: $ Date: Time: Fee: $ Total: $ Receiving Bank: Wire Transfer ABA#: Physical Address: Beneficiary Name: Beneficiary Account #: Beneficiary Address: *Further Credit Bank: *Account: Special Instructions: Your Name: Your Physical Address: Purpose of Wire: Your Account # at FLNB: Your Phone Number: Your Cell Phone Number: I agree to the representations, warranties, terms and conditions on page 2 of this agreement. Your Signature: YOU WILL BE CHARGED A $10.00 FAX FEE TO COMPLETE THIS TRANSACTION IN ADDITION TO THE $20.00 WIRE TRANSFER FEE. You must have a sufficient COLLECTED Balance in the account to be charged. In order to complete your Wire Transfer Request, you MUST provide the following documents:
