UNIVERSITY OF ALASKA
DOMESTIC WIRE REQUEST FORM
NO ELECTRONIC SIGNATURES ARE ALLOWED SUCH AS DOCUSIGN. THIS DOCUMENT CONTAINS PII AND
CONFIDENTIAL BANKING INFO. IN ORDER FOR FUNDS TO BE SENT, AUTHORIZED SIGNER MUST APPROVE
AND SUBMIT THIS REQUEST VIA EMAIL TO UA-CASH@ALASKA.EDU.
*Indicates required Field
Note: Requester must sign and be different than authorized signer.
Authorized Signer call back phone#: ________________________
*USD amount ____________________________ *Transfer date: ____________________
CASH MANAGEMENT USE ONLY
*U.S. Department of the Treasury OFAC verified (Both SDN list and Sanctioned Countries must be checked):
LAST 4 Digits of Vendor/Payee Account #:
Has acct # changed for this
vendor? Circle one: Yes/No
If yes, has the new acct# been verbally verified with the vendor?
Circle one: Yes/No Initials of Auth signer:_____________________
Additional Info & Reason:
*Banner fund & org # wire transfer fee _____________________________________
FURTHER CREDIT (Required to further credit another financial institution, i.e. credit union small bank –
*Requester phone #:___________