LANDMARK WIRE TRANSFER FORM

Outgoing Wire

 

Domestic

International

 

$20.00 fee Waive fee

 

$45.00 fee Waive fee

 

EMPLOYEE:                                                             DATE:                    TIME:                                   

 

RECURRING CODE:  ____________________         APPROVING OFFICER:  ________________________

 

ORIGINATOR INFORMATION

Name:  

 

Account to charge:

 

Address:

 

 

 

Wire Amount:

$

 

Non-customer wire transfers:

 

ID # __________________________

 

ID Type _______________________

Cash (exception basis only)

 

 

 

Telephone:

VERIFICATION FROM CUSTOMER IS REQUIRED

Customer Signature:

Reason for wire (i.e.: Business, loan, etc.):

 

 

 

BENEFICIARY’S BANK

CORRESPONDENT BANK/ INTERMEDIARY BANK (if applicable)

Name:

 

 

Name:

City, State:

 

 

City, State:

Routing #:

 

 

Routing #/Swift Code:

Swift Code:

Account #:

 

BENEFICIARY INFORMATION

 

**Operations Use Only**

Name:

 

Correspondent Bank

FRB FHLB UBB

Address:

 

Contact:

 

Account #:

 

Completed by:

 

 

 

Balance in Account:

 

 

Other Information:

 

 

 

Questions call Operations at 763-753-7602      Operation Fax 763-753-5375