(Box 2) You may select one of three ways to transfer funds. US Dollars to Foreign Currency – The debit from your account will be made in US $ and converted to the appropriate foreign currency specified on this wire form prior to being sent to the beneficiary bank. Foreign Currency to Foreign Currency – This method should be used when a specific amount of foreign currency needs to be received at the beneficiary bank. The US $ equivalent of the currency amount will be debited from your account. US Dollars to US Dollars – The full amount of the wire will be sent in US $ and debited from your account. If the account in the foreign country is NOT specifically designated to receive US $, the foreign bank will convert the funds into the foreign country’s domestic currency upon arrival, using its own exchange rate, and applicable transaction fees. This may also delay the proper and timely crediting of funds. If unsure, contact the beneficiary to get specific instructions from the foreign bank where the account is held.
Place a check mark next to your selection – please select only one of the check boxes below. Please initial the form once you have made your selection.
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US Dollars to Foreign Currency |
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Foreign Currency to Foreign Currency |
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US Dollars to US Dollars |
Initials:_________ |
Transaction Amount _________________________ HFCU wire charge: $50.00 |
Foreign Currency Type:____________________________________________________ |
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(only needed if one of the Foreign Currency options is selected above) |
If this is a “US Dollars to US Dollars” transaction, please provide the Correspondent Bank information below:
Correspondent Bank:____________________________________________________________ |
ABA #/SWIFT Code: ______________________________________ |
(If left blank, the Correspondent Bank will be assigned by the transaction processor)
(Box 3) Please print clearlyBeneficiary Information
Beneficiary’s Bank Name: ______________________________________________________________ Bank Address: _______________________________________________________
City/Town: _______________________________________ Province: ___________________________________________ State/Country: ________________________________________
Postal Code: ____________________________ * Bank/Sort Code: ____________________________________________ Swift Number: ________________________________________
* Bank code is required for GBP wires (Great Britain/United Kingdom). * 5-digit Sort Code is required for wires going to Kenya.
Beneficiary Name: ________________________________________________________________________________________________________________________________________
Beneficiary Address: __________________________________________________________________ City/State/Zip: ________________________________________________________
**Beneficiary Account Number/IBAN: _________________________________________________________________________________________________________________________
**A valid IBAN is required for all wires going to Europe. ** An 18-digit CLABE # is required for all wires going to Mexico.
***Reason/Reference for Payment: _____________________________________________________ *** Beneficiary Phone #: _________________________________________________
***All wires (arriving in foreign currency) to Thailand, South Korea, China and Indonesia must include a reason for payment, and a phone number for the beneficiary.
(Box 4) I understand that Hanscom Federal Credit Union (HFCU) is acting strictly as an agent and will act only on the instructions that I have provided. In the event that the information provided is incomplete or incorrect, I release HFCU from any liability that may result. The payee or any Financial Institution (FI) may be identified by name, account number, or ABA #. HFCU (and other institutions) may rely on the account or other identifying number as the proper identification, even if it identifies a different party or institution. Regulation J governs a wire transfer cleared through the Federal Reserve. I authorize HFCU to transfer funds as described herein and debit my account in the amount transferred, plus applicable charges. I understand that should I request a wire by fax or secure email, the wire will be verified by a call-back from a Credit Union employee to me using a telephone number currently on file at HFCU. This call-back may require me to send a secure email verifying the authenticity of the fax request.
A Pre-Payment Disclosure MUST be handed, verbally stated, securely emailed, or faxed to you for review and approval prior to the wire being sent. After documented approval by you is received, the wire will be sent and a Receipt Disclosure will be handed, securely emailed, or faxed to you for your records.
Member/Joint Owner Signature__________________________________________________________________ Date _______________________
Verifying Information to be completed by HFCU Employee – Entire section must be completed |
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Print Employee Name completing form |
Operator # ______________ Extension # _____________ Branch Office |
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Employee Signature completing form _________________________________________________________
Verification of Member – Type of ID _______________________________ ID # ___________________________ Expiration Date of ID ________ / _______/ ______
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Member Signature was Verified by Employee Name _________________________ Date verified ________/ ______ /______ Time verified |
________________________ |
Employee Signature processing Call-back |
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Secure Email or Fax? |
Yes |
No If Yes, has member been reached for verification? Yes No Date verified |
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Time verified _____________ |
For Branch or Call Center – Secondary Verification for completeness of form – Employee Signature OTHER than above ___________________________________________
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Information for Outgoing Wire to be completed by Operations Team Member ***(OFAC Verified by: |
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on |
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*** |
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Prepayment Disclosure: |
Handed Verbal Secure Email Faxed Receipt Disclosure: Handed Secure Email Faxed Permission to Mail by Member |
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Was wire cancelled by member within 30 minutes of making payment? Yes No |
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Initiated by |
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Approved by |
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EW Funds Withdrawn by |
. EW Funds Verified by |
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