Outgoing Wire Transfer Request

* indicates a required field

A notarized Wire Transfer Password Form must be completed before requesting a wire transfer. If you have not completed this form, please visit an Allegacy financial institution or contact us either through Live Chat or by calling Member Services at 336.774.3400/800.782.4670. Domestic wire transfer requests must be submitted by 4:00 PM Eastern Time. International wire transfer requests must be submitted by 2:30 PM Eastern Time. Click Here before submitting this application for an explanation of required information.

*Member Name:

*Address:

*Member Number:

*City:

*Contact Phone:

*State:

*Zip:

*Wire Password

*Email

Wire Transfer Instructions

I have contacted the receiving financial institution to obtain the wiring instructions for this transaction. I understand that the routing transit/ABA number for the receiving institution may be different from the routing transit/ABA number used for the receiving party’s checking account. Allegacy Federal Credit Union (and other institutions) may rely on the account and other identifying numbers as proper identification. I understand that if the wire transfer is cleared through the Federal Reserve, the transaction is governed by Regulation J. I authorize Allegacy Federal Credit Union to transfer funds as described below and debit my account in the amount transferred, plus a wire transfer fee as disclosed in Allegacy Federal Credit Union’s Savings & Checking Rate and Fee Schedule.

*Transfer Date:
*Amount:
*Account # to be charged:
Intermediary Financial Institution information (if applicable):
*Receiving Financial Institution Name:
*Receiving Financial Institution ABA/RT # or IBAN/swift code:
*Beneficiary Name:
*Beneficiary Account Number:
*Beneficiary Address:
*Receiving Financial Institution Address and Phone Number:
*Reference Information for Receiving Financial Institution:
*Purpose for the Wire Transfer:

Credit Union Use Only

__________________________	__________	COLLECTED FEE	YES NO	__________________________
PROCESSED BY	DATE			APPROVED BY

__________________________	__________	COLLECTED FEE	YES NO	__________________________
APPROVED BY	DATE			DATE
OFAC Screen Completed/Entered by: _________________ Date: ________ Time: ______
Password Verified by: _____________________ Time: ________
Verified and Transmitted by: _________________ Date: ________ Time: ______			Fed Reference Number: _____________________

Required Information

A separate wire transfer form is required for each outgoing wire transfer request. Any wire transfer requests submitted before 4:00 PM Eastern Time will be processed the same day. An Allegacy representative will contact you to verify the information on the request form and to complete the wire transfer.

Wire Transfer Password Form - This form must be completed before submitting an Online Wire Transfer Request. The form must be notarized and mailed to Allegacy at PO Box 26043, Winston Salem, NC 27114-6043. If you are near a local Allegacy financial center, the Wire Transfer Password Form must be completed at a financial center. If you are not local, please contact us either through Live Chat or by calling Member Services at 336.774.3400/800.782.4670 to have the form sent to you.
Member Name and Member Number - The name of the member that is requesting the wire transfer. You must be logged into the account the funds will be withdrawn from.
Contact Phone - Telephone number that will be used to contact you to verify the wire transfer instructions. This telephone number must match the telephone number provided on the Wire Transfer Password Form.
Address, City, State, and Zip - The mailing address for the member making the wire transfer request.
Wire Password - The password provided on the original Wire Transfer Password Form.
Transfer Date - Date the wire transfer will take place.
Amount - Amount to be wired. This amount does not include the wire transfer fee:

Domestic wires - a fee of $20.00 will be charged to the account.
Foreign wires - a fee of up to $45.00 will be charged to the account.

Account # to be Charged - The account number the funds will be withdrawn from.
Intermediary Financial Institution - Some receiving institutions cannot accept a wire transfer directly from Allegacy. If an institution requires a third party to process the wire transfer, the third party’s information should be entered here. This section is required for all international wire transfers.
Receiving Financial Institution - The financial institution that will be receiving the funds from the wire transfer.
Receiving Financial Institution ABA/RT # or IBAN/swift code - The routing and transit number for the financial institution that will be receiving the wire transfer. Contact the Receiving Financial Institution to obtain this number. The Receiving Financial Institution may use a different routing and transit number for wire transfers than the routing and transit number used for a checking account. The IBAN/swift code is required for all international wire transfers.
Beneficiary Name - The name of the individual/company on the account the funds will be deposited into. This section is required for all international wire transfers.
Beneficiary Account Number - The account number the funds will be deposited into. This section is required for all international wire transfers.
Beneficiary Address - The address for the individual/company who will be receiving the funds. This section is required for all international wire transfers.
Receiving Financial Institution Address and Phone Number - The address and telephone number for the financial institution that will be receiving the funds. This section is required for all international wire transfers.
Reference Information for Receiving Financial Institution - Use this section to provide any additional information that the Receiving Financial Institution will need to complete the wire transfer. This section is required for all international wire transfers.
Purpose for the Wire Transfer - This section is required for all international wire transfers.

* indicates a required field