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