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					                                                Wire Transfer Request Form
                                      All domestic wires are subject to a $15 fee. Cut off time is 2 pm
                                                   All information is required except (*)

                                     Wire Amount: $_______________ Savings or Checking

                                           Sender / Payer Information
      Member Name: ________________________ Member Account #: ______________________________
      Address:______________________________________________________________________________
      City / State/ Zip: _______________________________________________________________________
      Contact Information____________________________________________________________________
      *Special Instructions from sender_________________________________________________________
      _____________________________________________________________________________________


                                            Recipient/ Payee Information
      Name: ____________________________ Member Account #: _________________________________
      Address:_____________________________________________________________________________
      City / State / Zip: ______________________________________________________________________
      Identifier Information (SSN, TIN DL#)_______________________________________________________

                                 Recipient / Payee Financial Institution Information
      Institution Name: ____________________________ Routing / ABA #: __________________________
      City / State / Zip: ______________________________________________________________________


      This funds transfer agreement governs the procedures and responsibilities concerning payment order initiated by the Account Owner through
      KaiPerm Credit Union. You agree to be bound by any payment order, whether or not authorized, issued in your name accepted by us in
      compliance with the security procedures chosen by you in this agreement. The Credit Union may rely on the member or other identifying
      number as the proper identification, even if it identifies a different party or institution. We will follow the security agreement procedures
      identified in this agreement. You agree that these procedures are commercially reasonable methods of verifying payment orders. Any
      electronic funds transfer that we permit are subject to Article 4A of the Uniform Commercial Code will be subject to the provisions for this
      Agreement and the provisions of the Uniform Commercial Code as enacted by the State of Oregon.

      You authorize the Credit Union to transfer funds as described herein and debit your account in the amount transferred, plus applicable fees.



                Signature:
                ________________________________________________________________
                (Required for fax and in person requests and/or for requests for wire transfers to an account of
                which the member does not have access to)




                                                      Internal Use Only
                                   Date: _______________ Time:__________ Teller# ___________

Member verification: _______________________________________________________________________________

              Entered by: ______________ Verified by: ___________                           Logged by: ____________________

				
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