3832224510

WELLS

FARGO

Wire Transfer Services Outgoing Wire Transfer Request

A customer or team member, with the customer presentcompletes this form when requesting to send a wire.Outgoing wires can onły 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. Notę: Wells Fargo Wire Transfer Sen/ices will route wires based on correspondent banking relationships.

"Today's Datę    *Send Datę (If next day submit wire after 3:30 CT. Storę must hołd if other than today or next day datę.)

1. Originatort Information
•(ustom eCs Name 1		•Phone Number
•Customers Address, Gty, State, Zip Codę i __ ____ ____
Tax ID Type - Type & No. are required when customert account is not debited 1 G Sotial Security G (TIN □ Non-U-S. Citizen without TIN G Employer ID	Tm ID Na(tfnorMtoen prowdeAfcn ID #,Passpo*t # & Country): l
•Name on ID used by customer
*1st ID Type, number, issued by State/Country,& Expiration Datę	•2nd ID Type, number, issued by State/Country, & Expiration Datę
•Transfer from WeHs Fargo Bank 10 digit Account No. (Must be chedting, «wings, martet ratę or Wholesale cheddng account)		jUS. Dollar Wire Amount
•International Wire onfy: Foreign Currency Type/Name (FX will be used unless spedfied otheiwise)	l*Cunency Codę (If known)	•foreign Currency Amount
2. Benafłdary/Redpient Information (TifebtittatfaNterMpiwtrftiwwto

•Beneficiary/Retipient Name    •Benefkiary Account Number (or Mejciran (LAK # if applicaWe)

I

Benefidary Address, City,State, Zip Codę

I_:_

Benefidary Phone Number

Information for the Benefkiary (iiwoice number, Purchase order number, etc)

3. Beneficjary Bank Information rrhbbthefmwKiaiimtitt^orbcBfcwd^fu.MMTfliLyndOwłw™

•Benefkiary Bank RTN or SWIFT Bank Identifier Codę (BIC)    *1ntemational Sort/Routing/Clearing Codę (if applkabłe) •Benefkiary Bank Name

Benefkiary Bank Address, City, State, Zip Codę & Country (optłonal Information)

Information for Benefidary Bank (wires to Mewcan banks requice the CLABE account number in the Benefidary instrudions to eroure correct paymenL)

4JnUrmtdlaiy Bailk IwfogmattoiirWibhafkwHfafimtHutiootWttiifwwTmgt pass tiw»^ibHwewKhh>jtltt<foalbt«>«fldary bank.) ThbstctknisopdMal and not mąśni for aH wire. FlMtttnoaethatFi^ni—yhuatmdśąierKfcngonWtfeFargoBaoaCscofTe^orKiem rt^twmhgR.

Optional: ^#lntermediary Benefkiary Bank RTN or SWIFT BIC    International Sort/Routing/Clearing Codę (if appfcabłe)

•Intermediary Bank Name    "Intermediary Bank Account No.

Intermediary Bank Address,Gty,State,Zip, Country (optional Information)

Information for Intermediary Bank

5. Wire Fn & Customar Signature_

Wire Fee Amount (the Transfer Ftwn account will be charged the fee.) The region that houses    *AU where the Originatort account is located *Fee Amount

the account being debited determines the fee amount. Use the fee Information availabłe throogh Teamworks and/or the Bankert Guide. Do not use SVT/SVP for fee when account is

not in your region.    _____|$

Wy signature here indicates agreement to all of the information on this Outgoing Wire Transfer Reguest and to the terms and conditions on the second page of this reguest. Wells Fargo Bank is authorized to refy on the information on this Reguest in making the requested funds transfer.    »oate

X

6. Bank Uf Only - Bank Approyal & Excaption Procass - FoHowing MUST bl compiated for ALL outgoing wirts,

■ - -• — - - .

Ratę

Contz^ct No. (regaired when $15,600 or morę U.S4)

FXTraderContact

•Wire Tri nsaction/FA	S Nimfa	c*						-■ - — , - ■-----	fi- .'ir, vA^,:V“^Sł-’. *- »ir4C -. y . v
•When Custometf account is not debited, the WIP Account is fundedby: iGWdCa* | Q WdbyOfctt			^; • -ś	|0 Wdtbroughaawrt other than dieddng, $*rfng$,MRAJKorHogan. RefenenceAccL#
InitłnedbyandAUł ftotkfpm. L____Ił_				*		|i- 3 *V '	lx "