Wire Transfer Request Form
Wire transfer cut-off time is 2:30PM EST
Basic Wire Information Domestic
Wire Effective Date |
Wire Amount ($) |
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Originator’s Name |
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International |
FOREIGN CURRENCY |
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Currency Code |
Currency Amount |
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Rate |
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Charge |
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Total in USD ($) |
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Account to be Charged |
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(Debit) |
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Originator’s Street Address |
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City |
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State |
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Zip |
Receiving Bank/Beneficiary’s Bank
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Name |
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Street Address |
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State |
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Zip |
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Receiving Bank’s ABA No. |
(Bank’s ABA No. or S.W.I.F.T. Code) |
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Pay Thru Bank |
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Name |
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Street Address |
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State |
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Zip |
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Bank’s ABA No. |
(Bank’s ABA No. or S.W.I.F.T. Code) |
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Beneficiary |
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Name |
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Street Address |
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Zip |
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Account No. |
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Phone (if applicable) |
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Intermediary Bank Name |
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Name |
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Street Address |
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Zip |
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Bank’s ABA No. |
(Bank’s ABA No. or S.W.I.F.T. Code) |
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Originator to Beneficiary Information (OBI)
Originator to Beneficiary Information (OBI)
Bank to Bank Information (BBI)
Bank to Bank Information (BBI)
(See reverse side for Terms and Conditions)
I acknowledge that I have verified the above referenced information and hereby authorize NCB, FSB to transfer the funds accordingly. I understand that NCB, FSB will use its best efforts to handle the wire transfer that I have requested, but it does not guarantee either the delivery or the subsequent recovery of the funds to be transferred. I understand that if I have described the beneficiary of this wire transfer order inconsistently by name and account number or other identifying number, payment might be made by the beneficiary’s bank on the basis of the number which I have furnished even if it identifies a person different from the named beneficiary, and such circumstances will not excuse me from my obligation to pay the amount of the wire order. Other banks involved with the transfer may assess handling charges, in addition to those assessed by NCB, FSB for a wire transfer, or any other condition beyond NCB, FSB’s reasonable control. NCB, FSB will not be liable for losses from inoperable communication facilities, the failure of any agent used by NCB, FSB for a wire transfer, or any other condition beyond NCB, FSB reasonable control. For International wire transfers, NCB, FSB will not be responsible for losses from fluctuations in foreign exchange rates or impairment of foreign currencies, and additional risks from the economic, social and political environments of foreign countries, and governmental policies that may prevent successful completion of the wire transfer. I further acknowledge and agree to the attached Wire Request Terms and Conditions.
Authorized Signer’s Name |
(Please Print) |
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Date |
ID Type and Number |
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Authorized Signature |
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Signer’s Contact Information |
(Telephone and/or Email Address) |
Internal Dept. Request
Prepared By
Authorized By |
(Please Print) |
Authorized Signature* |
Date |
I hereby authorize execution of this funds transfer transaction and confirm that it is in compliance with the Wire Transfer Procedures. I also confirm that the account has sufficient funds to cover the wire amount and all applicable fees.
Wire Transfer Request Form
Wire transfer cut-off time is 2:30PM EST
Wire Request Terms and Conditions
These terms and conditions govern the wire request made by the person or entity executing the request form (“Customer”) and are in addition to, and do not limit, other terms and conditions that may be provided by NCB, FSB (“Bank”).
1. Cancellation of Payment Orders
Customer shall have no right to cancel or amend a wire request order after it has been received by Bank. However, Bank shall make a reasonable effort to act on Customer’s request for cancellation or amendment of a payment order prior to the time that the Bank executes such payment order, but shall have no liability if such cancellation or amendment is not affected.
2. Debits and Overdrafts
Bank may, but is not obligated to, debit any authorized account of Customer for any payment order executed by Bank pursuant to a wire request, even if the debit creates or increases an overdraft in that account. Unless otherwise provided in a separate credit facility between Bank and Customer, in the event that an overdraft is created or increased, Customer shall cause sufficient available funds to pay the amount of the overdraft to be deposited into or credited to that authorized account by the close of that banking day. Any overdraft existing at the close of a banking day is immediately due and payable without notice or demand. Notwithstanding the foregoing, Bank shall be under no obligation to execute any such payment order if there are insufficient funds in the applicable authorized account.
3. Fedwire and Applicable Rules
Each payment order or cancellation thereof may be furthered by any bank by use of the funds transfer system of the Federal Reserve Banks (“Fedwire”). The rights and obligations of Bank and Customer with respect to any payment order, any part of which is carried out through the use of Fedwire, will be governed by any applicable laws, the regulations of the Board of Governors of the Federal Reserve System, and the operating circulars of the Federal Reserve Banks and, to the extent applicable, the International Rules.
4. Fees
Customer shall pay Bank the fees set forth in the Bank’s applicable Fee Schedule.
5. Regulatory Compliance
Compliance with any regulatory requirement by Bank, including background checks required by U.S. Treasury’s office of Foreign Assets Control’s (“OFAC”) does not exempt Customer from conducting its own OFAC checks or evaluations or taking such other action as may be required by its own government regulations. Upon request, Customer shall provide Bank with documentation evidencing such compliance, including without limitation copies of applicable policies and procedures, risk assessments, and other documentation relating to wire activity. Notwithstanding Customer’s own clearance thereof, Bank reserves the right to refuse processing of any payment it deems may be in violation of any regulatory guidelines including OFAC and Bank is not responsible for any resulting delayed or canceled payment.
6. No Extension Of Credit
Nothing in these terms and conditions nor any course of dealing between Customer and Bank constitutes a commitment or obligation of Bank to lend money to Customer or obligates Bank to extend any credit to Customer, to make a loan to Customer, or otherwise to advance funds to Customer to pay for any payment order contrary to Bank’s published availability schedules.
7. Indemnity
Customer shall defend, indemnify, and hold harmless Bank and its officers, directors, employees, agents, parent, subsidiaries, and affiliates, from and against any and all damages, costs, liability, and expense, whatsoever (including attorneys' fees and related disbursements) incurred by Bank or its agents in connection with the wire request, including arising out of any claim by a third party alleging that a Customer payment order contravenes or compromises the rights, title or interest of any third party, or contravenes any law, rule, regulation, ordinance, court order or other mandate or prohibition with the force or effect of law; provided, however, such indemnity shall not apply to the extent such damages are caused solely by Bank’s breach of these Terms and Conditions, fraud, gross negligence or willful misconduct.