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W
IRE TRANSFER REQUEST


Date _____________________________________
Date Required


Department _______________________________
Document #/AP Use Only _______________
Requested By _____________________________ Phone # _____________________________
Authorized Signature ________________________ PO/TE # _____________________________
Purpose

WIRE INSTRUCTIONS
click
here Please complete all boxes
Domestic



International


Intermediary Bank

Attach documentation for Bank and Account Information

Bank Name

Bank Address

Bank ID
Account Holder's Name
Account Holder's Address
Account Number
CURRENCY TYPE USD - United
States

Dollars

AMOUNT
Bank Country
in currency selected

INDEX FUND
ORG ACCOUNT
PROGRAM
__________ ____________ ___________ _________ ___________ $__________
__________ ____________ ___________ _________ ___________ __________
__________ ____________ ___________ _________ ___________ __________








WIRE FEE 0.00

TOTAL $__________
0.00
PLEASE ATTACH INVOICE OR TE TO BE PAID
Special Instructions




Controller’s Office/ORA Approval

Last Revised 10/05/15