Secure Wire Transfer Request Form

Please select: Domestic Outgoing Wire $20.00 - cutoff time 4:00 p.m. CST International Outgoing Wire $50.00 - cutoff time 1:00 p.m. CST

Wire Originator Information

Name Address City State Zip Code Daytime Phone Number Dollar Amount Account to be debited Purpose of Wire

Recipient Bank Information

Bank Name Bank Address and or Branch Country City State Zip Code Bank ABA or Routing Number For Credit to (Name of Beneficiary) Beneficiary's Address Country City State Zip Code Beneficiary's Account Number

Were you promised a large amount of money in return for sending this wire? Yes No

Are you wiring funds which were deposited by someone you do not know? Yes No

Were you instructed to wire money in order to claim lottery or prize winnings? Yes No

Are you wiring money in response to a guaranteed credit card or loan offer? Yes No

Were you instructed to send money to claim an inheritance? Yes No

Are you wiring money in response to an Internet or phone offer? Yes No

Are you sending money to someone you don't know? Yes No

Are you sending money to participate in a foreign lottery? Yes No

Authorization

I understand that Foundation One Bank (FOB) 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 FOB from any liability that may result. I authorize FOB to transfer funds as described herein and debit my account in the amount transferred, plus applicable fees. I understand that FOB can place no guarantee with regard to the length of time it takes for the funds to be credited to the receiving account after a wire is initiated. I further understand that if a wire is returned to FOB due to erroneous information provided, wire fees will not be refunded.

Please read the Terms and Conditions and check the box below to certify that you have read and agreed to all agreements listed.

I have read and agree to the Terms of the Foundation One Bank Funds Transfer Authorization.