Please complete this form, print it out, and fax it to
United Pacific Bank at (626) 965-2840.

 

WIRE TRANSFER APPLICATION AND INSTRUCTIONS
 

  
I hereby appoint United Pacific Bank my agent for the purpose of effecting a payment per the details given on the face of this order. When I direct the funds received from me to be remitted in foreign values, the Bank may, in its discretion, convert said funds received from me into said foreign values at the Bank's selling rate on the day such funds are received, unless I direct the Bank in writing to charge an account maintained by me in the foreign funds to be remitted for the amount of the remittance.

The Bank's statement in writing that it has made such a conversion referred to above shall be conclusive, and in such a case, the order in this instrument shall be construed as an immediate purchase by me of the amount of said foreign funds at my sole risk. The said remittance may be made by the Bank through its customary channels, and the Bank is absolved from any and all liabilities for loss arising from any cause beyond its control, including, but not limited to the following:

(1) The act, failure be neglect of any agent or correspondent selected by the Bank for the remittance thereof:
(2) Any delay, error, omission or default of any mail, telegraph, cable or wireless operator,
(3) The acts or edicts of any government or governmental agency or other group or groups exercising governmental powers, whether de jure or de facto.

When a Request contains a name and account number, payment may be made by Bank and/or by other banks to which a Request is forwarded based solely on the account number even if the acco6nt number identifies a beneficiary different from the beneficiary named by Customer. Customer acknowledges that Bank and other banks to which a Request is forwarded may rely on any bank identification number supplied by Customer as a means to identify any other bank, even if the identification number is different than the bank named by Customer.

Customer acknowledges that payment orders may be received by us and may be executed by us using Federal Reserve Communication System (Fedwire), and will be subject to Regulation J and its accompanying Subpart B.

The Bank shall be under no obligation to obtain the receipt of the payee. The Bank on request, will use its best efforts to trace payment. No request for tracing shall be made prior to three weeks from date of this order.

The Bank shall not be under no liability to make any refund prior to receipt by it of continuation or order of cancellation from the correspondent, agent or subagent engaged by the Bank to effect the transmittal and in the case of funds already converted, only on the basis of the Bank's buying rate on the day refund is made less the expenses of the Bank, its correspondents and agents. The Bank may discharge said liability, if any, by assigning to me its interest in any credit which may be established as a result of this order with its correspondent, agent or subagent.





 

 

 

 PAYING BANK

 NAME
 ADDRESS
 INSTRUCTIONS
 ABA REFERENCE

 PAYEE

 NAME
 ADDRESS
 INSTRUCTIONS
 ACCOUNT NO.

 TELEPHONE NO.
 REMITTER

 NAME
 ADDRESS
 INSTRUCTIONS
 ACCOUNT NO.
 TIN #
 ID #

IN PAYMENT OF THE ABOVE  REMITTANCE  FOR COST PLUS ALL  BANK CHARGES:

 (__________) CASH ATTACHED (Subject to authorized receipt issued by  Bank)

 (__________) CHECK IN YOUR FAVOR NO._________________________
(Subject to final payment in good funds)
                                   DRAWN ON __________________________________

 (____________) PLEASE DEBIT MY/OUR ACCOUNT NO. _______________


BY SIGNING THIS WIRE TRANSFER APPLICATION AND INSTRUCTIONS, I/WE AGREE TO ALL TERMS AND CONDITIONS SET FORTH. PLEASE EFFECT PAYMENT ACCORDING TO MY/OUR INSTRUCTIONS.


 ________________________________          ________________________
 CUSTOMER/REMITTER'S SIGNATURE         
DATE

 

REMITTANCE AMOUNT

US $___________________________

 

 BALANCE BEFORE   $____________________________

 HOLD  $_______________________________________

 BALANCE AFTER $_____________________________

 OUR WIRE FEE  $______________________________

 TOTAL CHARGE  $_____________________________

 


  TELLER
 
 
  CHECKER
 
 
  REMITTANCE SECTION
 
 
  APPROVAL
 

 

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