Student Accounts SA03
STUDENT WIRE REQUEST FORM
Purpose of Form: This form should be completed by a student wishing to receive a refund payment via wire (for
example, when funds are in USD or other currencies are required).
Requestor Information:
Date (YYYY-MM-DD): _______________________ Name: ___________________________________
Student Number: __________________________ Email: ____________________________________
Wire Information:
Amount: __________________________
Purpose of Wire/Message to Payee: ____________________________________________________
Payee Information:
Payee Name: ____________________________________
Address 1: __________________________________________________________________________
Address 2: __________________________________________________________________________
City: ___________________ Province/State: ________________ Country: _____________________
Postal/Zip Code: ___________________________ Payee Telephone: __________________________
Payee Email: ____________________________________
Bank Information:
Bank Name: ________________________________________________________________________
Address 1: __________________________________________________________________________
Address 2: __________________________________________________________________________
City: ___________________ Province/State: ________________ Country: _____________________
Postal/Zip Code: _______________ IBAN/Bank Account Number: ____________________________
Swift Code: ___________________ Routing Code or ABA Number: ___________________________
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Signature:
Your typed name below indicates your approval of the form and confirms that all information is accurate.
_____________________________________
Once complete, please return to the Office of the Cashier, Room 1118 CHT, or email to cashiers@uwindsor.ca
For Finance (Internal) Use Only:
Reviewer Name: ____________________________________
(check each box below for confirmation)
Balance Confirmation: Payee Confirmation:
Banking Confirmation:
Deposit Forfeiture? (circle) Yes or No Currency: _________________________________
Initials of Reviewer: _________________ Review Date (YYYY-MM-DD): ________________
Approver: _________________________________________
Approval Date (YYYY-MM-DD): ________________________
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