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
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
+33 4 94 90 41 93- + 33 6 09 60 68 07
Could this be 12879 00001 00221116458 67?
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.
