Fillable UNIVERSITY OF ALASKA DOMESTIC WIRE REQUEST FORM (University of Alaska)

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UNIVERSITY OF ALASKA DOMESTIC WIRE REQUEST FORM (University of Alaska)

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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
03/20
UA AUTHORIZATION:
*Requested by:
*Date:
Note: Requester must sign and be different than authorized signer.
*Authorized by :
*Date:
*
Authorized Signer call back phone#: ________________________
TRANSACTION INFORMATION:
*USD amount ____________________________ *Transfer date: ____________________
BENEFICIARY/VENDOR INFORMATION:
CASH MANAGEMENT USE ONLY
*Verified/Approved by:
Date:
From Bank Account #:
JV#:
*U.S. Department of the Treasury OFAC verified (Both SDN list and Sanctioned Countries must be checked):
http://www.treas.gov/ Initials:___________________
*Vendor/Payee Name:
*
LAST 4 Digits of Vendor/Payee Account #:
Has acct # changed for this
vendor? Circle one: Yes/No
*US Receiving Bank Name:
*ABA/Routing #:
Reference #:
Additional Info & Reason:
*Banner fund & org # wire transfer fee _____________________________________
FURTHER CREDIT (Required to further credit another financial institution, i.e. credit union small bank –
final destination):
Vendor/Beneficiary Bank
ABA/Routing #:
Bank Address:
*Requester phone #:___________
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UNIVERSITY OF ALASKA DOMESTIC WIRE REQUEST FORM (University of Alaska)

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Completed 28 August 2020

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