Wire Transfer Request Form

WIRE TRANSFER REQUEST
SOLICITUD DE TRANSFERENCIA DE FONDOS

Fax Number: (305) 597-1744
e-mail: wiretransfer@BanescoUSA.com
DATE: CURRENCY: AMOUNT:

(FECHA) (MONEDA) (MONTO)
WRITTEN AMOUNT:
(MONTO EN LETRAS)
DEBIT ACCOUNT NUMBER:

(NUMERO DE CUENTA A DEBITAR)
ORIGINATOR NAME:
(NOMBRE DEL ORDENANTE)
ORIGINATOR ADDRESS:
(DIRECCION DEL ORDENANTE)
CITY: STATE / COUNTRY / ZIP CODE:

(CIUDAD) (ESTADO / PAIS / CODIGO POSTAL)
Receiving Bank ABA:

ABA del Banco receptor:
BENEFICIARY ACCOUNT NUMBER:
(NUMERO DE CUENTA DEL BENEFICIARIO)
BENEFICIARY NAME:
(NOMBRE DEL BENEFICIARIO)
BENEFICIARY ADDRESS:
(DIRECCION DEL BENEFICIARIO)
CITY: STATE / COUNTRY / ZIP CODE:
BENEFICIARY BANK ID NUMBER (ABA/SWIFT CODE):
(CODIGO DE IDENTIFICACION DEL BANCO BENEFICIARIO)
BENEFICIARY BANK NAME:

(NOMBRE DEL BANCO BENEFICIARIO)
BENEFICIARY BANK ADDRESS:

(DIRECCION DEL BANCO BENEFICIARIO)
CITY : STATE / COUNTRY / ZIP CODE:

INTERMEDIARY BANK NAME and ID Number (aba/Swift code)

(NOMBRE DEL BANCO INTERMEDIARIO)
INTERMEDIARY BANK ADDRESS:

(DIRECCION DEL BANCO INTERMEDIARIO)
CITY : STATE / COUNTRY / ZIP CODE:

REFERENCE FOR BENEFICIARY / CEDULA NUMBER:
(REFERENCIA PARA EL BENEFICIARIO / NUMERO DE CEDULA)
16 CHARACTERS MAX (MAXIMO 16 CARACTERES)
ORIGINATOR TO BENEFICIARY INFORMATION:
(INFORMACION DEL ORDENANTE AL BENEFICIARIO)
BANK TO BANK INFORMATION:
(INFORMACION DE BANCO A BANCO)
CUSTOMER SIGNATURE:
(FIRMA DEL CLIENTE)
FOR BANK USE ONLY (PARA USO DEL BANCO)

PREPARED BY: AUTHORIZED BY:
PLACE STAMPS HERE:

CONF BY:_______________DATE________________TIME___________
CUSTOMER NAME: _______________________Acct No.___________________

Telef.__________________ACCT. BAL.________
FTA ON FILE:Y___N___
CHALLENGE
QUESTIONS_________________________________
____________________________________________
____________________________________________
WIRE DPT. E.__________R.___________
TRN:: ___________________________________________________

Wire Transfer Request Form

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Wire Transfer Request Form

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WIRE TRANSFER REQUEST

SOLICITUD DE TRANSFERENCIA DE FONDOS

DATE: CURRENCY: AMOUNT:

DEBIT ACCOUNT NUMBER:

CITY: STATE / COUNTRY / ZIP CODE:

Receiving Bank ABA:

BENEFICIARY BANK NAME:

BENEFICIARY BANK ADDRESS:

CITY : STATE / COUNTRY / ZIP CODE:

INTERMEDIARY BANK NAME and ID Number (aba/Swift code)

INTERMEDIARY BANK ADDRESS:

CITY : STATE / COUNTRY / ZIP CODE:

FOR BANK USE ONLY (PARA USO DEL BANCO)

PLACE STAMPS HERE:

CUSTOMER NAME: _____Acct No._

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