Secure Web Form

* Indicates field is mandatory
• Amount ($xx.xx)
  OK Amount ($xx.xx) is required
• Purpose of Payment
  OK Purpose of Payment is required

Sender Information

• Name
  OK Name is required
• Debit Account (Must be 10 digits)
  OK Debit Account (Must be 10 digits) is required

Recipient Information

• Receiving Bank Name
  OK Receiving Bank Name is required
• Bank ABA (Domestic) or Swift Code (International)
  OK Bank ABA (Domestic) or Swift Code (International) is required
• Receiving Bank Address
  Optional OK Receiving Bank Address is required
• Recipient Name
  OK Recipient Name is required
• Credit Account
  OK Credit Account is required
• Recipient Address (If a full address is not available, please include as much of the address as possible
  OK Recipient Address (If a full address is not available, please include as much of the address as possible is required
IF APPLICABLE
• Second Receiving Bank Name
  Optional OK Second Receiving Bank Name is required
• Bank ABA (Domestic) or Swift Code (International)
  Optional OK Bank ABA (Domestic) or Swift Code (International) is required
• Second Receiving Bank Address
  Optional OK Second Receiving Bank Address is required
• Additional Payment Instructions (Examples; Invoice Number, Escrow Number, For Further Credit Information)
  Optional OK Additional Payment Instructions (Examples; Invoice Number, Escrow Number, For Further Credit Information) is required

International Wire Information (If Applicable)

• Currency Type (All wires will be submitted in US dollars unless another currency is specified)
  Optional OK Currency Type (All wires will be submitted in US dollars unless another currency is specified) is required

• OK is required