Fillable Generic Fee Waiver Form for Financial Institutions (Florida Department of Financial Services)

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Generic Fee Waiver Form for Financial Institutions (Florida Department of Financial Services)

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Generic Fee Waiver Form for Financial Institutions
________________________________________________, a financial institution operating in Florida, agrees
to voluntarily waive the wire-transfer or processing fees to our customers for wire-transfer payments for
Holocaust-related reparations or restitution. Upon receipt of a written request and reasonable documentation
from our customers, we will waive all of our fees associated with processing these wire-transfer payments.
Name of Institution (please print): _____________________________________________________________
Signatory (please print): ____________________________________________________________________
Title (please print): ________________________________________________________________________
Signature: _______________________________________________________________________________
Contact Telephone Number: _________________________________________________________________
Information to be posted on Website (please print):
Name of Financial Institution: ________________________________________________________________
Address for Sending Written Requests: ________________________________________________________
City: _________________________________________ State: _____________________ Zip: ____________
Contact Telephone Number for Questions (preferably toll-free): _____________________________________
Contact the Florida Department of Financial Services:
Telephone or Email:
Lynn Grossman
(850) 413-4160
Lynn.Grossman@MyFloridaCFO.com
Mail:
Lynn Grossman
Florida Department of Financial Services
200 E. Gaines, 524B
Tallahassee, FL 32399
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Generic Fee Waiver Form for Financial Institutions (Florida Department of Financial Services)

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Completed 29 July 2020

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