Today’s Date
Date Payment Required
Name of Person Preparing Form & Department
Payment Type
Domestic Wire
International Wire
Payee’s Name & Address
This must be the exact name & address on the
payee’s bank account.
Payment Amount
(Record amount to be wired in the currency indicated on
Wire Instructions Attach wire instructions from payee’s bank.
Bank Name
Bank ABA Number*
Bank Account Number**
BIC (Swift Code)**
Sort Code (UK Only)**
Intermediary Bank Information
(ABA Number & SWIFT Code)^
Additional Payee Payment Instructions
# Suppliers are encouraged to sign up for ACH/Direct Deposit. Domestic Wires are not encouraged and require
the approval of the Director of Disbursements.
* ABA required for domestic wire transfer.
** See the Wire Transfer Policy for definitions
^ If the receiving bank’s wire transfer instructions specifies the use of an intermediary bank, record that
information here.
Wires to India and China require the
business purpose/reason for the wire and
the relationship between the remitter
(Brown) and the beneficiary (payee).