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Wire Request Form Originator Information SOCIAL SECURITY # TRANSFER FROM: MEMBER ACCOUNT # WITH SUFFIX (00, 10, ETC.) MEMBER NAME (FIRST, MI, LAST) E-MAIL ADDRESS STREET/MAILING ADDRESS CITY STATE ZIP HOME PHONE # WORK PHONE # AND EXT. CELL PHONE # MEMBER SIGNATURE DATE Wire Transfer Information AMOUNT$ TYPE:# Domestic Wire ($20) # Foreign Wire ($35) INTERMEDIATE INSTITUTION (if applicable) ACCOUNT NO. RECEIVING INSTITUTION ABA ROUTING NO. (9 Digits) CREDIT TO: (Beneficiary) ACCOUNT NO. ADDRESS OF BENEFICIARY APT. # CITY STATE ZIP OTHER BENEFICIARY INFO CU Use Only EMPLOYEE RECEIVING REQUEST DATE & TIME OF REQUEST # Member Identification Verified and Attached# Funds Verified# Wire Transfer Agreement Signed By Member # Callback by Accounting Department# OFAC Check by Accounting Department EMPLOYEE LOADING WIRE DATE & TIME WIRE LOADED CONFIRMATION # WESCORP REP. WESCORP RELEASE VERIFICATION BY TIME NOTES
