Fillable OUTGOING DOMESTIC WIRE TRANSFER REQUEST (Georgia's Own Credit Union)

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OUTGOING DOMESTIC WIRE TRANSFER REQUEST (Georgia's Own Credit Union)

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P.O. Box 105205, Atlanta GA 30348 phone: 404.874.1166 - 800.533.2062 georgiasown.org
Last Revision Date 01/2020
OUTGOING DOMESTIC WIRE TRANSFER REQUEST
1) Domestic Wire Origination Instructions:
Amount:
$
From Account:
Name:
Purpose of Wire:
Address:
Contact #s: Mobile:
Home:
• 2) Do you request wires to this same beneficiary frequently? - YES NO, this is a singular occurrence.
• 3) Would you like to receive an email when this and other wires are completed on this same account? - YES NO
(If yes, we will set up a notification profile to the email address on file for the account facilitating the wire request)
4) Receiving Financial Institution: (Or correspondent FI if wire transmits through two FIs with valid ABA routing numbers)
FI Name:
FI Number:
(ABA Routing)
Address:
5) Beneficiary FI Information, when applicable: (Only if a correspondent FI is used in section 4 above)
FI Name:
FI Number:
(ABA Routing)
Address:
6) Beneficiary Information: (Person or business name on account where funds are being deposited)
Beneficiary Name:
Account:
Address:
7) Optional Beneficiary Reference: (Keyword unique to your wire +)
Limit to 16 Characters:
+ This OPTIONAL line may include a unique keyword (16 characters or less) to identify your wire. Examples may include: Invoice, Fall Tuition, Rent, Hospital Bills, Etc.
8) Optional Originator to Beneficiary Instructions: (Special instructions or communication to the beneficiary ++)
++ This OPTIONAL line may include special instructions given by the beneficiary to identify your wire so that your account is properly updated.
Examples may include your utility bill account number, your closing mortgage file number, your property address, a reference number to your personal loan for payoffs, etc.
By signing below, I agree to the following statements along with the additional terms, conditions and disclosures listed in the
Membership and Account Agreement incorporated herein by reference. I authorize Georgia’s Own Credit Union to transfer funds from
my account or jointly held account as set forth in the instructions noted herein (including debiting my account) and agree that such
transfer of funds and/or the return of unapplied wire funds are subject to fees as listed on Georgia’s Own Credit Union’s fee
schedule. I agree to hold Georgia’s Own Credit Union harmless if funds transferred as a result of this agreement are misapplied or
returned by the receiving Financial Institution. I also agree to hold Georgia’s Own Credit Union harmless if the funds are not received
and credited or are credited incorrectly due to information I have given Georgia’s Own Credit Union. I also understand that the funds
transfer may be subject to fees by the Receiving Depository Institution and if I dispute these fees, will direct all inquiries to that
institution.
Signature:
Date:
For your security and protection, processing of wires may require a call back verification from Georgia's Own Credit Union to
the phone number on file for the account facilitating the wire request. Failure or inability to complete the call back verification
step may result in the delay or termination of your wire request.
Member initials of acknowledgement of call back verification requirement
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OUTGOING DOMESTIC WIRE TRANSFER REQUEST (Georgia's Own Credit Union)

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Completed 23 December 2020

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