Wire Transfer Request Form - 2220745

Wire Transfer Request
Please print and sign this form. Everence must have this form completed and signed before any wire can be sent. You can deliver this form
to any branch, send via fax, or upload securely through online banking. If you have questions, call your local branch office or 800-451-5719.
Date________________________________________________ Amount of wire __________________________________(USD)

Member number _____________________________________ Account type: ■
 Checking  Savings Account suffix ________
Member name ______________________________________________________________________________________________

Member address ____________________________________________________________________________________________
Phone number_________________________________ Branch ____________________________________________________
Type: ■
 Domestic  International
Purpose of international wire ___________________________ Reason if other _______________________________________
Routing instructions (See page 3 for additional information)

1st stop: Receiving bank
Street address
City, state and country
(3400) Bank number
Credit to (beneficiary bank)
(if different from receiving bank)
Street address
Account number
(4100) Additional information
Credit to (intermediary bank)1
1
Beneficiary bank data required if this field is used
Account number
(5200) Additional information
Beneficiary details (4200)

Beneficiary name
Beneficiary address
Account number
Additional information
Additional information _______________________________________________________________________________________
___________________________________________________________________________________________________________
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Signature
I agree that my account will be debited for this service. I hereby authorize Everence Federal Credit Union (Everence) to transfer funds by wire
as shown above. I understand that the account shown will be debited for the amount of the wire, plus any applicable fees. I agree to hold
Everence harmless if the funds are not received and credited due to incorrect or incomplete instructions or information. A tracer fee (research
request) will be deducted from my account in the event this wire is lost through no fault of Everence. I further acknowledge that this request
does not violate the provisions of United States law as it applies to wire transfers.
____________________________________________________
Authorized member signature – must match signature on file
After submitting this form, a credit union representative will call you to confirm and initiate the wire. International
wires received by 11 a.m. will be processed the same day. Domestic wires received by 3 p.m. will be processed the
same day.
For office use only
Request made by mail, fax or secure upload through online banking

Signature matched to file
Made verification call to requester
In person/video banking
Member identity verified
Wire amount greater than $5,000
Wire department verified with member
Call-back process completed for loan proceeds or investment purchase over limit
_____________________________________________________ _____________________________________________________
Verified by: employee signature Manager signature (needed over $5,000)
Initiated by __________________________________________ Verification number ___________________________________

Verified by __________________________________________
Comments
2220745 continued
Wire transfer form instructions
General information
Date Date the request is being made.
Amount of wire Insert the amount of the wire in U.S. dollars.
Member number Identify the member number, account type and account suffix the funds are to be wired from.
Member name Identify the member name as it shows on your account.
Member address Identify the member address as it shows on your account.
Phone contact number Include your current phone number. Remote verifications must be completed using the phone number on
your account.
Type Domestic – if the final stop is to another bank located in the United States.
International – if the final stop is to a bank located outside of the United States.
Purpose of International Wire  Capital Transfer  Charity Donation  Current Transfers: General Govt
 Current Transfers: Other Sectors  Dividend Account  Employee Compensation
 Family Support  Goods Trade  Operating Expenses  Service Trade  Trade Related  Other
Routing instructions
Receiving bank Enter name of bank receiving wire. This would be the first (and possibly the only) bank the wire would
route through.
Street address Required for all wires. Must be a street address. PO boxes not permitted without a specific street
address.
City, state and country Required for all wires. International addresses may contain a province or territory instead of a state.
Bank number Insert the 9 digit bank ABA number if wire is domestic. Format 123456789.
If the wire is international you will need one of the following (usually a SWIFT code):
SWIFT (Society for Worldwide Interbank Financial Telecommunications) refers to a connected SWIFT ID.
Format ABCD EFGH
IBAN (International Bank Account Number). Consists of 34 alpha-numeric characters
Please confirm wire instructions with the receiver’s financial institution.

Beneficiary bank This will be the recipient's bank (if different than the receiving bank).
Credit to (Beneficiary bank) Enter name of bank associated with beneficiary, if different than receiving bank.
Street address* Required: must be a street address. PO boxes not permitted without a specific street address.
City, state and country* Required: international addresses may contain a province or territory instead of a state.
Account number Enter account number associated with beneficiary bank.
Additional Information Enter beneficiary bank branch name, address, and/or other information (e.g. apply to jumbo CD for
settlement services).
Intermediary bank Will rarely be used. It is the name of the bank (if any) between the receiving bank and the beneficiary
bank. If an intermediary bank is used, the beneficiary bank information is required as well.
Intermediary bank name Enter name of bank between receiving bank and the beneficiary bank, in sending wire.
Account number Enter account number associated with intermediary bank.
Additional information Enter intermediary bank branch name, address, and/or other instructions.
Beneficiary details
Beneficiary name Enter the recipient's name as it appears on the recipient's bank account where the money is being wired.
Beneficiary address Required for all wires. Must be a street address. PO boxes not permitted without a specific street
address.
City, state, and country Required for all wires. International addresses may contain a province or territory instead of a state.
Account number Enter the recipient's bank account number as it appears on the recipient's bank account where the money
is being wired.
Additional information
Additional information Enter any information further relating to wire (e.g. reference Invoice 102 for $350 and Invoice169 for
$450).
2220745 3

Wire Transfer Request Form - 2220745

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Wire Transfer Request

Date______________ Amount of wire (USD)

Member name ______________________________________________________________________________________________

Purpose of international wire _ Reason if other _____________

Routing instructions (See page 3 for additional information)

Beneficiary details (4200)

For office use only

Request made by mail, fax or secure upload through online banking

Initiated by ________ Verification number _

Please confirm wire instructions with the receiver’s financial institution.

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