Fillable Outgoing Funds Transfer Request (Access Credit Union)

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Outgoing Funds Transfer Request (Access Credit Union)

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The Outgoing Funds Transfer Request (Access Credit Union) form is 2 pages long and contains:

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  • 14 check-boxes
  • 57 other fields

Country of origin: CANADA
File type: PDF

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Outgoing Funds Transfer Request
SENDER INFORMATION
FINANCIAL INSTITUTION NAME TRANSIT NO.
FINANCIAL INSTITUTION ADDRESS FINANCIAL INSTITUTION PHONE NO.
SENDER NAME ACCOUNT NO.
SENDER ADDRESS (street, city, province, postal code)
Complete the following if the currency of purchase differs from the currency of the funds transfer.
CURRENCY OF PURCHASE MEDIUM OF EXCHANGE OF PURCHASE (e.g. cash, cheque, etc.) AMOUNT OF PURCHASE
$
Complete the following for all non-account holder funds transfers of $1,000 or more, or for account holders if the information is not on le.
OCCUPATION / NATURE OF PRINCIPAL BUSINESS DATE OF BIRTH PHONE NO.
ID TYPE AND NO.
Complete the following for all international funds transfers of $100,000 or more if the Sender has not been previously identied as a PEP.
POLITICALLY EXPOSED FOREIGN PERSON (PEP) DECLARATION
Have you or any member of your family* ever been employed as a judge or senior ofcial** in a foreign state?
YES (If Yes, attach Form 2351)
NO
BENEFICIARY INFORMATION
FINANCIAL INSTITUTION NAME TRANSIT NO. / ABA / SWIFT
FINANCIAL INSTITUTION ADDRESS FINANCIAL INSTITUTION PHONE NO.
BENEFICIARY NAME ACCOUNT NO. (or IBAN if applicable)
BENEFICIARY FULL ADDRESS SORT CODE (if applicable)
® is a registered certication mark owned by the World Council of Credit Unions and is used under license.
PAGE 1 OF 2
R 5
© 1991 – 2009 CENTRAL 1 CREDIT UNION COPY 1 – SENDER COPY 2 – CREDIT UNION FORM 1171 (R.07/09)
INTERMEDIARY FINANCIAL INSTITUTION INFORMATION
(Mandatory if sending Canadian dollars to the US.)
INTERMEDIARY FINANCIAL INSTITUTION NAME ABA / SWIFT
INTERMEDIARY FINANCIAL INSTITUTION ADDRESS ACCOUNT NO.
*Family includes: **A PEP means a person who holds or has held one of the following ofces or positions in or on behalf of a foreign state:
• the applicant's mother's or father's child
• the applicant's spouse or common law partner
• the applicant's spouse's or common law partner's
mother or father
• the applicant's mother or father
• the applicant's child
• judge
• head of a government agency
• deputy minister or equivalent rank
• head of state or head of government
• military ofcer with a rank of general or above
• ambassador or attaché or counsellor of an ambassador
• president of a state-owned company or a state-owned bank
• leader or president of a political party represented in a
legislature
• member of the executive council of government or member
of a legislature
TRANSFER AMOUNT AND CURRENCY
DATE TIME AM / PM TRANSFER AMOUNT ($CDN equivalent)
$
US $ / FOREIGN CURRENCY AMOUNT
$
FUNDS TRANSFER CURRENCY EXCHANGE RATE
CDN
US
OTHER ______________________________________
RECEIVING COMMISSION
$
PAYABLE TO RECIPIENT UPON IDENTIFICATION
CHARGES
$
SENDING CLERK NAME OTHER
$
TOTAL (fees plus amount)
$
ADDITIONAL PAYMENT DETAILS
(e.g. invoice number)
ADDITIONAL INFORMATION FOR FINTRAC REPORTING
ORDERING CUSTOMER DETAILS BENEFICIARY CUSTOMER DETAILS
PHONE NO. DATE OF BIRTH (individuals only) PHONE NO. DATE OF BIRTH (individuals only)
OCCUPATION (individuals only) OCCUPATION (individuals only)
ID TYPE AND NO. (individuals only) ID TYPE (individuals only)
ORDERING CUSTOMER THIRD PARTY INFORMATION BENEFICIARY CUSTOMER THIRD PARTY INFORMATION
IS THIS TRANSFER BEING SENT ON BEHALF OF A THIRD PARTY? WILL THIS TRANSFER BE RECEIVED ON BEHALF OF A THIRD PARTY?
YES
NO
YES
NO
CUSTOMER TYPE CUSTOMER TYPE
INDIVIDUAL
ENTITY
INDIVIDUAL
ENTITY
THIRD PARTY NAME THIRD PARTY NAME
THIRD PARTY FULL ADDRESS THIRD PARTY FULL ADDRESS
DATE OF BIRTH (individuals only) DATE OF BIRTH (individuals only)
OCCUPATION (individuals only) OCCUPATION (individuals only)
ID TYPE (individuals only) ID TYPE (individuals only)
This section is provided to assist nancial institutions with FINTRAC EFT Report requirements. Make a reasonable effort to complete this section
if the transfer is $10,000 (Canadian equivalent) or more, and is sent in US dollars outside of Canada. A nancial institution that sends this type of
transfer via the Money Transfer System (MTS) is generally the last Canadian nancial institution to process the transfer and is therefore required
to report the transfer to FINTRAC.
If the nancial institution is aware of multiple transfers conducted by or on behalf of the same person that, in total, equal or exceed $10,000 (Canadian
equivalent) within 24 consecutive hours, the nancial institution must report the transfers to FINTRAC.
FUNDS TRANSFER REQUEST PAGE 2 OF 2
Funds transfer requests are nal once sent. I (the "Sender") understand that there is no guarantee that any refund will be received if a recall is requested,
and that processing charges may be deducted from any refund received. In the case of a recall request on a foreign currency transfer, any refund will
be paid using the rate of exchange in effect on the date of the refund and not the rate of exchange in effect on the date of the original transfer.
Sender Signature
x
Date
SENDER AGREEMENT
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Outgoing Funds Transfer Request (Access Credit Union)

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Completed 6 June 2021

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