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Domestic Wire Fillable

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File type: PDF

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Request for Domestic Wire Transfer
RETURN FORM TO:
Treasury, Tax & Investments, 300 College Park, St. Mary’s Room 405, Dayton, OH 45469-1665
Date Received: ______________________
Department Name: Department Contact:
Department Zip: Contact Phone:
Payee (Beneficiary) Name & Address:
Bank Name ABA Number
Beneficiary Bank Account
Name (must match Payee
name above and tax form)
Bank Account Number
Payment Support including Purpose: (Attach original
invoice, vendor’s independent confirmation of bank
account information, Form W-9)
Transfer Amount: Currency: USD
Department FOAPAL String:
FUND ORGANIZATION ACCOUNT PROGRAM ACTIVITY LOCATION AMOUNT
Signature Approvals (Additional signatures required if payment is above signature thresholds)
Requestor Signature
Print Requestor Name
Date
Department Head/Budget Manager Signature
Print Department Head/Budget Manager Name
Date
Dean/Vice President Signature
Print Dean/Vice President Name
Date
VPFAS Signature
Print VPFAS Name
Date
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Domestic Wire Fillable

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Completed 24 February 2020

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