22 East Flagler Street Miami, FL 33131
1-800-727-5626 or 305-577-1328
Please contact us at 1-800-727-5626 or 305-577-1328 before submitting this form
Print Application!
Wire/Funds Transfer Payment Order FEE $25.00
The undersigned originator requests payment to be made to the beneficiary of account number named below. To the extent not prohibited by law, the undersigned agrees that this wire transfer is irrevocable and that the sole obligation of the institution named above is to exercise ordinary care in processing this wire transfer and that it is not responsible for any losses or delays which occur as a result of any other party's involvement in processing this transfer.
Wire funds to:
| BENEFICIARY BANK DATA | ORIGINATOR DATA |
| ABA Routing Number: | Sender's Name: |
| Name of Institution: | Address: |
| Branch Information: | |
| BENEFICIARY DATA | Phone Number: |
| For further credit to: | Driver's License Number: |
| Beneficiary's Name: | Account Number: |
| Address: | Dollar Amount: $ |
| Account Number (if any): | Senders Signature: X |
| Instructions: | |
For final credit to:_____________________________
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| ORIGINATING BANK PROCESSING DATA | |||
| Security Code: | Transfer Number (if not numbered above): | ||
| Code Word: | Date: Time: Fee: $ | ||
| Code Word Sequence Number: | Method of Payment: | ||
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Originating Bank's Account Number:
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| Dollar Amount $: | Prepared By: | ||
| (Note: Transfers in amounts of $3,000 or more may require additional recordkeeping) |
Record Kept? Yes | ||