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Wire Transfer Form

Originator

Name: Telephone:
Physical Address:        
City: State: ZIP:
Account Number:

Intermediary Financial Institution (if applicable)

Financial Institution: Routing Number:
City: State:

Beneficiary Financial Institution

Financial Institution: Routing Number:
Physical Address:        
City: State: ZIP:
Account Number:

Beneficiary

Name: Account Number:
Physical Address:        
City: State: ZIP:

Originator to Beneficiary Text:

Originating Bank to Beneficiary Bank Text:

Disclosures

In order for us to process your request correctly, we may need to contact you to verify some of the information or request additional documentation. When you submit this request, you certify that everything stated above is true and accurate.

I AGREE
By clicking the "Submit" button below, I hereby certify that I understand that First State Bank of Bedias is acting strictly as an agent and will act only on the instructions that I have provided. In the event that the information provided is incomplete or incorrect, I release First State Bank from any liability that may result. I authorize First State Bank to transfer funds as described herein and debit my account in the amount transferred, plus applicable charges. Wire Transfers are scheduled to be processed prior to 2:00 pm. Any wire transfer request received after 2:00 pm will be processed the following business day. Wire transfers processed through the Federal Reserve are governed by Regulation J.

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