Retain original copy in Bank and provide a copy to the customer, including both pages 1 and 2.
WTR6603 (11-06 106148FO) Page 1 of 2
Wire Transfer Services
Outgoing Wire Transfer Request
A customer or team member, with the customer present, completes this form when requesting to send a wire. Outgoing wires can only be sent for Wells Fargo customers.
Retain the original copy in the bank and provide a copy to the customer ensuring you give the customer the Agreement for Outgoing Wire Transfer Request (page 2 when
form is accessed on-line & preprinted on the back of printed forms). Required information is noted with an asterisk. Note: Wells Fargo Wire Transfer Services will
route wires based on correspondent banking relationships.
*Today’s Date *Send Date (If next day submit wire after 4:30 CT. Store must hold if other than today or next day date.)
1. Originator’s Information
*Customer’s Name *Phone Number
*Customer’s Address, City, State, Zip Code
Tax ID Type – Type & No. are required when customer’s account is not debited Tax ID No. (if non-citizen provide Alien ID #, Passport # & Country)
Social Security ITIN Non-U.S. Citizen without TIN Employer ID
*Name on ID used by customer
*1st ID Type, number, issued by State/Country, & Expiration Date *2nd ID Type, number, issued by State/Country, & Expiration Date
*Transfer from Wells Fargo Bank 10 digit Account No. (Must be checking, savings, market rate or wholesale checking account) *U.S. Dollar Wire Amount
*International Wire only: Foreign Currency Type/Name (FX will be used unless specified otherwise) *Currency Code (if known)
*Foreign Currency Amount
2. Beneficiary/Recipient Information (This is the ultimate recipient of the wire transfer funds.)
*Beneficiary/Recipient Name *Beneficiary Account Number (or Mexican CLABE # if applicable)
Beneficiary Address, City, State, Zip Code
Information for the Beneficiary (invoice number, Purchase order number, etc.) Beneficiary Phone Number
3. Beneficiary Bank Information (This is the financial institution or broker dealer (i.e., Merrill Lynch) where the beneficiary maintains their account.)
*Beneficiary Bank RTN or SWIFT Bank Identifier Code (BIC) *International Sort/Routing/Clearing Code (if applicable)
*Beneficiary Bank Name
Beneficiary Bank Address, City, State, Zip, Country (optional information)
Information for Beneficiary Bank (wires to Mexican banks require the CLABE account number in the Beneficiary Account number field to ensure correct payment.)
4. Intermediary Bank Information (This is a financial institution that the wire must pass through before reaching the final beneficiary bank.) This section is optional and not
required for all wires. Please note that routing may be altered depending on Wells Fargo Bank’s correspondent relationships.
Optional: *Intermediary Beneficiary Bank RTN or SWIFT BIC International Sort/Routing/Clearing Code (if applicable)
*Intermediary Bank Name *Intermediary Bank Account No.
Intermediary Bank Address City, State, Zip, Country (optional information)
Information for Intermediary Bank
5. Wire Fee & Customer Signature (Additional fees from intermediary and beneficiary banks may be charged to international transactions – see Fees Section on page 2 of this form.)
Wire Fee Amount (the Transfer From account will be charged the fee.) The region that houses the account being
debited determines the fee amount. Use the fee information available through Teamworks and/or the Banker’s Guide.
Do not use SVT/SVP for fee when account is not in your region.
*AU where the Originator’s
account is located
*Fee Amount
$
My signature here indicates agreement to all of the information on this Outgoing Wire Transfer Request and to the terms and conditions on the second page of this Request.
Wells Fargo Bank is authorized to rely on the information on this Request in making the requested funds transfer.
*X
*Date
6. Bank Use Only — Bank Approval & Exception Process – Following MUST be completed for All outgoing wires
International Wire Foreign Currency Information
Rate Contract # (required when $15,000 or more U.S. $) FX Trader Contact
*Wire Transaction/FAS Number
*When Customer’s account is not debited, the WIP Account is funded by
Paid Cash Paid by Check
Paid through account other than checking, savings, MRA, TRS or Hogan. Reference Acct.: #
*Initiated by and AU # *First Approval Second Approval, if applicable
X X
7. Bank to Complete following as required/needed.
Verification of Originator (Telephone, Fax, written requests or business account validate the originator is an authorized signer & document below or attach supporting documentation.)
Method of identification to verify requester’s authority to charge account for the wire Caller’s immediate phone number
Reason caller cannot come into the Bank Caller’s location
Company Home Other:
Confirmation of Request (Banker calls customer for confirmation)
Phone # to call to verify request Time of call to customer Source used:
Bank Records Telephone Directory Other:
Name of person placing call Customer Contact Name Customer
Approved the transfer Denied the transfer
Telephone, Fax or Written Request Approvals
Account Officer Date Next level of approval if applicable Date
DELUBAC et CIE
SARL DDL CONSULTANTS WORKSHOP CDW12 COMPTE BIS
FR76 1287 9000 0100 2211 1645 867
Quartier La Daby - Pas de Pouyen Villa La Lisopette 83330 LE BEAUSSET FRANCE
Tom Hahn registration for CDW 12
SWIFT Code : DELUFR21
Could this be 12879 00001 00221116458 67?
DELUBAC et CIE
16, place Saléon Terras - 07160 Le Cheylard - France
International division : Phone + 33 4 75 29 49 92 - Fax : + 33 4 75 29 52 02 - E-mail : international@delubac.fr
CCBPFRPP (This may be wrong. If this does not work, Please try CCBPFRPP.)
NATIXIS (This may be wrong. The correct name may be NATEXIS.)
An additional piece of information you may need is: USD Correspodnign bank is JP Morgan Chase Bank, SWIFT Code CHASUS33.
Retain original copy in Bank and provide a copy to the customer, including both pages 1 and 2.
WTR6603 (11-06 106148FO) Page 2 of 2
Agreement For Outgoing Wire Transfer Requests
Responsibility of the Bank. The Bank is only responsible for making a good faith effort to execute the payment order described in
the Outgoing Wire Transfer Request (the ‘’Order’’). The Order may be sent by wire, telegraph, telephone, cable, or whatever other
transmission method the Bank considers to be reasonable. The Order may be transmitted directly to the Beneficiary Bank, or
indirectly to the Beneficiary Bank through another bank, government agency, or other third party that the Bank considers to be
reasonable.
Agent. Bank may use agents of its choice to perform any of its obligations.
Limitation of Liability. The Bank will not be liable for any loss or damage due to the failure, delay, or error of: (1) the method of
transmission selected by the Bank, (2) a third party selected by the Bank to receive the Order, or (3) the Beneficiary Bank. IN NO
EVENT WILL THE BANK BE LIABLE FOR DAMAGES ARISING DIRECTLY OR INDIRECTLY IF THE ORDER IS EXECUTED BY
THE BANK IN GOOD FAITH AND IN ACCORDANCE WITH THE TERMS OF THIS AGREEMENT. REGARDLESS OF THE FORM
OR NATURE OF ANY CLAIM OR ACTION, IN NO EVENT WILL THE BANK BE LIABLE FOR PUNITIVE, INCIDENTAL OR
CONSEQUENTIAL DAMAGES,WHETHER OR NOT THE BANK SHALL HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH
DAMAGES.
Reliance on Information Provided. Bank may rely solely (i) on the account number of the person (“Beneficiary”) who is to receive
the wire transfer rather than the Beneficiary’s name, and (ii) if provided by you, on the identification number of any other financial
institution through or to which the funds are to be transferred, rather than the name of the financial institution.
International Wire Transfers. If the Order is to be handled under any general or specific statute, rule, regulation or license of the
United States, or any agency thereof, it is understood that the Order shall be subject to such statute, rule, regulation or license.
Unless specified to the contrary, an Order will be in foreign currency (FX).The Bank will convert the amount to be transferred to the
currency of a designated foreign government or intergovernmental organization (“Foreign Currency”) at the Bank’s buying rate for
exchange in effect on the date the Order is executed. Upon request the Bank will convert the amount to be transferred to U.S. Dollars.
Refund. If the Beneficiary Bank does not pay the Beneficiary specified on the Order, a refund will be made only after the Bank has
received confirmation of the effective cancellation of the Order and the Bank is in free possession of the funds debited or earmarked
in connection with the Order. If the order is payable in Foreign Currency, the Bank will not be liable for a sum in excess of the value
of the Order after it has been converted from Foreign Currency to U.S Dollars at the Bank’s buying rate for exchange at such time as
the cancellation of the Order is confirmed by the Bank.
Failure to Transfer Proper Amount. If the Bank is notified that it did not transfer the full amount stated in the Request, the Bank’s
sole liability will be to promptly execute a second payment Order in the amount of the stated deficiency. If the Bank executes an
instruction in excess of the amount stated in the Request, to the extent that the originator does not receive the benefit of the Order,
the Bank will only be liable for any loss of the principal amount transferred in excess of the amount stated in the Request instructions.
Additionally, the Bank will be liable for the amount of interest the originator has lost due to the transfer of the excess amount,
computed at the then current Federal Funds rate. However, the Bank’s liability for loss of interest shall be limited to twenty (20)
calendar day’s interest. This section sets forth the Bank’s complete liability for the order issued under this agreement.
Finality of orders. The order will be final and will not be subject to stop payment or recall, except that the Bank may, at the
originator’s request, make an effort to effect such stop payment or recall. In such case, the Bank will incur no liability for its failure or
inability to do so.
Fees. In addition to the outgoing wire transfer fee, additional fees may apply. Additional fees can include, but are not limited to: an
additional fee for bank initiated transactions, amendment fees, statement fees, fees assessed by beneficiary and intermediary banks,
etc. Wells Fargo Bank Wire Transfer Fees are disclosed in your most recent Fee and Information Schedule and related amendments.
Acts of God. The Bank is excused for delays or failure to execute the Order to the extent that the delay or failure results from a cause
beyond the reasonable control of the Bank.