DOMESTIC Wire Transfer Request Form Date: Amount: PFCU Account

DOMESTIC Wire Transfer Request Form
**Important- wire transfers will not be processed without callback
verification to a phone number on record**
(Please Print Clearly)
Date: _______________________________ Amount: _________________________________
PFCU Account Number: _________________________________________________________
Member Name: ________________________________________________________________
Address:________________________________________________________________________
(P.O. Box # - not accepted)
Daytime Phone Number: _________________________________________________________
(Phone number must match a phone number on record)
Purpose of Wire Transfer:___________________________________________________________
Receiving Financial Institution:_______________________________________________________
ABA/Routing Number (9 Digit number):________________________________________________
Beneficiary Financial Institution: ___________________________________________________
Address:________________________________________________________________________
(P.O. Box # - not accepted)
ABA Routing number or Swift Code/BIC:_______________________________________________
IBAN number:____________________________________________________________________
(Required for European wire transfers)
Final Beneficiary to:_____________________________________________________________
Account Number:_______________________________________________________________
Address:________________________________________________________________________
(P.O. Box # - not accepted)
(Required)
A wire transfer agreement must be on file with the credit union before any wire transfer request will be
processed. Additionally, no wire transfer requests will be processed without proper identification provided (for
fax requests please follow up with a copy of identification) It has been explained to me that if the information I
have submitted on this form is incorrect in any way I will be charged for any additional costs which may occur.
I understand there will be a wire fee in accordance to our fee schedule.
Signature: ______________________________________________ Date: ________________
For PFCU Only:
Request made _________ in person _____ Fax _______ Letter
Information verified: 1.__________________ 2. __________________ 3.________________
ID Verified ______________________ Time rec:___________ Date rec:______________
Wire sent by: ____________________ Time:______________ Date:_________________
Wire verified by: _________________ Time:______________ Date:_________________
Revised 09 2010