Department Name: Contact Name: Phone: __________________

Name:Street Address:State/Province: Country: Postal Code: _____________

Account Title: Type of Account: _______________Account Number/IBAN: Select Type: _______________Institution Name: SWIFT/BIC/ABA:Street Address:State/Province: Country: Postal Code: _____________Intermediary Bank Information (Yes/No): Branch/Agency Code:

Payment Method: *Due Date:Remittance Currency:Invoice Currency: Invoice Amount:2nd Invoice Currency: 2nd Invoice Amount:Memorandum Info:Bene. Contact Phone: Foreign Tax ID :

REQUEST FOR WIRE TRANSFERS AND FOREIGN DRAFTS

City:

City:

BENEFICIARY INFORMATION

FINANCIAL INSTITUTION (FI) INFORMATION

Use this form to initiate all payments to foreign financial institutions (excluding Mexico and Canada) and domestic wire transfers.THIS FORM MUST BE FILLED OUT ELECTRONICALLY TO ENSURE ACCURACY AND TO VIEW EMBEDDED INSTRUCTIONS.

REMITTANCE INFORMATION

Select Type:

INTERMEDIARY FINANCIAL INSTITUTION INFORMATION (IF APPLICABLE)

Revised 5/2016

Account Number/IBAN: Select Type: _______________Institution Name: SWIFT/BIC/ABA:Street Address:State/Province: Country: Postal Code: _____________

By signing this form, the approver verifies that the Beneficiary is not on OFAC's list of sanctioned people and is not residing ina country sanctioned by OFAC. http://www.ustreas.gov/offices/enforcement/ofac/programs/index.shtmlDue to the geopolitical environment there may be risks associated with sending international wires from Purdue University.The Office of Treasury Operations will make every attempt to see that funds are received at their destination or returned to the University, the Office Treasury Operations cannot be held responsible for unapplied funds.

Departmental Approval Date Disbursements Approval Date

SPS Approval (If Applicable) Date OTO Initiation OFAC Date

Comptroller Approval Date OTO Release OFAC Date

INTERMEDIARY FINANCIAL INSTITUTION INFORMATION (IF APPLICABLE)

Select Type:City:

More information can be found at www.purdue.edu/treasuryop or send an email to treasury@purdue.edu

to FREH, Payroll Tax DepartmentPlease send completed form and Accounting Document via interoffice mail

Wire Initiation Approvals:Payment Approvals: