Wire Model Request Form

Treasury Operations

Money Movement Services

WIRE New Model Set-up Request

For ACH payments please, contact Charles Sinex in Accounts Payable.

Date

Person Making Request

Department

Campus Address

Phone Number

E-mail Address

WIRE REQUEST

Account in the Name of

Bank Name

Bank City, State

Account Number

Routing Number (ABA)

Purpose/Additional Information

APPROVAL

Account Supervisor (Printed)

Account Supervisor (Signed)

Fiscal Officer (Printed)

Fiscal Officer (Signed)

Please direct any questions to Treasury Operations.

After all approvals have been obtained, departments should forward the completed form to:

Treasury Operations, Poplars 205, IUBL

New Model Request circle one

Yes

Updating Existing Model #

This box is for Treasury use only

Director Approval_______Date_______

Model Creator__________Date_______

Model Approver________Date________

Model Number Assigned___________

Maximum Amount $

FIS________Date_______

Form________Date_______