DOMESTIC
WIRE TRANSFER REQUEST
(INTERNATIONAL WIRES NOT ACCEPTED)
PLEASE PRINT CLEARLY IN CAPITAL LETTERS: Complete the requested information, sign the form, and
fax it to 866-608-2635. If the request is received and verified by 3:00 p.m. Eastern time on a business day, it will
be sent the same business day. If it is received and verified after 3:00 p.m. Eastern time on a business day, it will
be sent the following business day. The wire transfer fee is $20.
Date of Transfer Request (mm dd yyyy)
Account Owner First Name
Account Owner Last Name
______________________________________________
Account Owner Street Address
______________________________________________
Account Owner City, State, Zip Code
Dollar Amount to be transferred
______________________________________________
Name of Beneficiary
______________________________________________
Account Number of Beneficiary to be credited
______________________________________________
Name of Beneficiary Bank
______________________________________________
City and State of the Beneficiary Bank
Bank Routing Number of the Beneficiary Bank
Account Number to be charged for the Wire Transfer
For Further Credit To and/or Additional Instructions:
AUTHORIZATION AND AGREEMENT
A wire transfer request is known as a “payment order” under
Article 4A of the Uniform Commercial Code.
1. We will verify that this payment order was authorized by
you if it exceeds $25,000 by calling the telephone number of
record for the account to confirm that you initiated the
request. You agree that this “callback” security procedure is
commercially reasonable and meets your security requirements.
We will not be liable for our refusal to honor any payment order if
we are unable to satisfy ourselves that you requested the
payment order.
2. You must ensure that the account number of the beneficiary
and the bank routing number of the beneficiary’s bank are
ABSOLUTELY ACCURATE. All banks process and post
payment orders by the account number of the beneficiary and by
the bank’s routing number and not by the name of the
beneficiary or by the name of the beneficiary’s bank. Please be
aware that we will not verify the accuracy of any account
number or routing number provided by you.
3. We reserve the right to delay or not to process payment
orders (a) to beneficiaries listed on the Specially Designated
National lists from the U.S. Department of Treasury, or (b) for
any reason related to an Executive Order of the President,
Foreign Governmental Embargoes/Sanctions, or directive of the
U.S. Department of Treasury.
4. We cannot revoke or cancel a payment order once it has
been sent and we will not be liable to you if we cannot recover
any funds already transferred.
5. We will not be liable for the insolvency, neglect, misconduct,
mistake, default or delay of any other bank, entity or person
whether or not that other bank, entity or person is our agent.
6. Our liability for failure to follow your instructions will be
limited to the amount of any payment order lost plus incidental
expenses and interest. In no event will we be liable for any
present or future indirect or consequential damages, punitive
damages or special damages, whether or not we were first
advised of the possibility of such damages. We reserve the right
to reject any payment order for any reason, including, but not
limited to, the lack of sufficient available funds in the account to
be charged.
7. You must notify us in writing of any error, mistake or
irregularity within 60 calendar days after the payment order was
requested. Thereafter, we will have no liability to you.
8. We do not send outgoing international wire transfers to
beneficiaries located in other countries.
Signature of Account Owner
