Wire Transfer Request

Wires Out Domestic Cutoff-  5:00 PM Eastern (EST)

Wires Out International Cutoff-  3:00 PM Eastern (EST)

Please complete the form below:

*Indicates a required field.
 

Member Information:
Member Account Number	*
Social Security Number	*
First Name	*
Last Name	*
Address	*
Address Line 2
City	*
State / Province	*	- - Choose One - - - - US States - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY - - Canada Provinces - - AB BC MB NB NL NT NS NU ON PE QC SK YT
Zip / Postal	*
Email	Please provide your Email if you would like to receive an automated form retrieval confirmation.
Wire Details:
Amount To Be Wired	*
From Account	*	Savings (Suffix A) Checking (Suffix 0)
Current Balance Of That Account	*
Fee Charged	*	Domestic- $20.00 International- $35.00
Intermediate Bank Information (Leave Section Blank if Not Intermediate):
Name of Receiving Bank
ABA Number
Receiving Bank Address
City
State/Province
Zip/Postal
Receiving Account Number
Name of Receiving Account Holder
Comments
Receiving Bank Information:
Name Of Receiving Bank	*
ABA Number	* Each institution is assigned an identifying ABA number. If you do not have this information, please contact the insitution and they can provide it to you.
Receiving Bank Address	*
City	*
State/Province	*	- - Choose One - - - - US States - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY - - Canada Provinces - - AB BC MB NB NL NT NS NU ON PE QC SK YT
Zip / Postal	*
Name Of Receiving Account Holder	*
Receiving Account Holder Number	*
Receiving Account Holder Address	*
Comments
ELECTRONIC FORM SUBMISSION AGREEMENT: By submitting this form I am verifying the following: 1. The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the transaction requested above. 2. I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union. 3. I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval. 4. Entering my first and last name in the Electronic Signature field stands as the equivalent of a handwritten signature. Therefore, by entering fraudulent or false information, you are committing forgery and are subject to the equivalent applicable laws and penal action. * Yes, I agree to the terms and conditions of sumbitting this form Electronically as outlined in the guidelines above.
Electronic Signature (please print your first and last name) *
Date *
Please enter the characters in the image for enhanced security (SSL) *
For Credit Union Staff: MSR Taking Wire Order: Staff Performing Wire: Staff Performing Verification: