International Wire Transfer Form

Today's Date

Financial Institution Receiving Funds

Receiving Bank Name (Final Destination)

Receiving Bank Address (Must be complete, include country)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Phone Number

Bank Fax Number

US Correspondent Bank Name

US Correspondent Routing/ Transit Number (ABA)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Account Number to credit (Final credit to)

US Dollar Amount $

Beneficiary of Account to credit (Name of Account holder)

Further credit to (name)

Additional Information or Special Instructions

Name

First Last

Member Number

SSN

Address

Street Address City State / Province / Region ZIP / Postal Code Country

E-mail address:

Wire funds from this account

Phone Number where you can be reached within 3 hours

I agree that my account will be debited for this service. I hereby authorize Omaha Federal Credit Union 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 the Omaha Federal Credit Union harmless if the funds are not received and credited due to incorrect or incomplete instructions or information.

Please note that Omaha Federal Credit Union can not make any guarantees that International Wires will be received the next day.

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