NOTICE: WIRE TRANSFERS MAY SETTLE BY THE ACCOUNT NUMBER, EVEN IF THE NAME PROVIDED IN THE PAYMENT ORDER DIFFERS FROM THE OWNER OF THE ACCOUNT. IT IS THE RESPONSIBILITY OF THE MEMBER SIGNING THIS FORM TO PROVIDE CORRECT INFORMATION.
DATE: WIRE AMOUNT:
MEMBER NAME (SENDER):
SENDER ADDRESS:
SENDER PHONE # HOME/WORK:
MEMBER ACCOUNT NUMBER TO DEBIT:
WIRE TO (FINANCIAL INSTITUTION NAME & ADDRESS):
ABA/ROUTING NUMBER:
FINAL CREDIT TO (RECEIVER):
RECEIVER ADDRESS:
RECEIVER ACCOUNT NUMBER:
SIGNATURE OF MEMBER:
BY SIGNING THIS YOU AUTHORIZE USDA CREDIT UNION TO TRANSFER FUNDS AS DESCRIBED HEREIN AND DEBIT YOUR ACCOUNT IN THE AMOUNT TRANSFERRED, PLUS A $15.00 FEE. INCORRECT WIRE INSTRUCTIONS WILL RESULT IN AN ADDITIONAL $15.00 WIRE FEE.