Trust Wire Authorizaon Form
Submit form to: accounng@myMidAmerica.com
F2103-004.1 (0521.v3) | MidAmerica Trust Wire Authorizaon Form
Secon A
Secon B
List of Authorized Signers
Domesc Wire Informaon
Employer
Reference
Bank Account Name
Authorized Signer First and Last Name
Employer Address
Authorized Signer First and Last Name
Authorized Signer First and Last Name
Authorized Signer Email Address
City, State, Zip
Authorized Signer Email Address
Authorized Signer Email Address
Authorized Signer Phone Number
Authorized Signer Phone Number
Authorized Signer Phone Number
Authorizaon
Secon C
I hereby cerfy that the wire banking details provided above are accurate. I authorize MidAmerica Administrave & Rerement Soluons to electronically credit the
account for Trust distribuon transacons and understand that this authorizaon will remain in eect unl revoked by an authorized signer in wring.
Quick Tip! The Reference eld helps you idenfy the wire transfer in your records. You can choose any descriptor that may be
helpful or leave it blank. Many employers include the name of their plan, their plan ID and/or their AUL policy number.
Signature
Signature Date (mm/dd/yyyy)Title
This form is required for the authorizaon and setup of domesc wire instrucons for Trust accounts with MidAmerica Administrave & Rerement Soluons
(MidAmerica). To ensure security and protect your account against fraudulent acvity, MidAmerica is required to verbally conrm all wire instrucons by phone call
and will do so by contacng the authorized signer(s) listed below. This form should not be used to request a distribuon from the Trust.
Please complete all elds below.
Name of Bank Bank Address
Bank Account Number ABA Roung Number
