Wire Transfer Request Form

200 Piedmont Avenue, Suite 1202 West Tower, Atlanta, GA 30334 Phone (404) 656-2168, Fax (404) 657-9066

This form should be sent to OTFS before 11:00 A.M. for same day wire.

* Requesting Agency Name:

* Authorized Wire Transfer Requestor:

* Contact Phone Number:

* Bank Name:

* Bank ABA (Routing Number):

Or Intermediate ABA:

* Bank Account Number:

* Bank Account Name:

* Customers Address:

* City, State and Zip Code:

* Has AP wire payment voucher passed the budget check?

Yes

* AP Voucher ID:

* Vendor Name:

* Reason for Payment:

* Amount to be wired:

* Scheduled Wire Date:

* Addenda Data/Reference:

By placing my initials below, I certify that the above information is accurate and that I am an authorized approver (Director/Manager) for same day wires.

* Approved by:

* Date:

You will receive confirmation of receipt from the OTFS Team. If no confirmation is received by 11:30 A.M. please contact Amy Stevens at 404-657-4204 or Lisa Hoover at 404-657-2094.

Office of Treasury and Fiscal Services Use Only

Date Received:

Date Wired:

Wired By:

Repetitive Code:

OTFS Form: 100-F

* Indicates Response Required