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Funds Withdrawal Request
This form is for the withdrawal of funds from your DriveWealth account. The account information provided below must match the account information on file.
Payments made to beneficiary other than the account name on file are considered third party. As a policy, DriveWealth will not make third party payments.
Section 1
SFPV000307
DriveWealth Account #: __________________________ angel.cavina@gmail.com
Primary Email: ___________________________
Angel Cavina Vargas
Customer Name(s): ______________________________________________________________________
Street Address:Rua Eugene Carriere, 17, Apto 83 Bloco Nice
_________________________________________________________________________
São Paulo, SP
City, Province: ____________________________________ Brazil
Country: ______________________________
308 86
Withdrawal Amount (in U.S. Dollars): $ _______.____
Method of Payment:
USD Electronic Check ___ ($3.00)
Bank Wire ___ ($25 Outgoing Domestic Wire Fee/$35 Outgoing International Wire Fee)
ACH__
✔ (0.25 cents)
Note: You can only withdraw funds with ACH and Wires if you have deposited funds in that way.
Section 2 (for Bank Wires)
Beneficiary Bank (Final Recipient’s Bank)
ABA Number / Swift Code: _____________________ Intermediary/Correspondent Bank (if necessary)
Community Bank
Bank Name: __________________________________ ABA Number / Swift Code: _____________________
5 Penn Plazza, New York, NY 10001
Bank Address: _________________________________ Bank Name: __________________________________
Angel Cavina Vargas
Beneficiary Name: ______________________________ Bank Address: _________________________________
8895641747
Bank Account #: ________________________________ Beneficiary Name: ______________________________
026073150
Bank Routing #: ________________________________ Bank Account #: ________________________________
Further Information: ____________________________ Bank Routing #: ________________________________
The Customer(s) confirm(s) that the information provided regarding the withdrawal from the account is accurate. This agreement shall be binding upon the
parties hereto and inure to the benefit of DriveWealth and its successors and assigns.
Customer Signature ___________________________ Date (mm/dd/year)06 14 ____ 2023
__/__/
Angel Cavina Vargas
Print Name __________________________________
(For Joint Accounts Only)
Customer Signature ___________________________ Date (mm/dd/year) __/__/ ____
Print Name __________________________________
---------------------------------------------------------------------------FOR BROKER USE ONLY--------------------------------------------------------------------------------
Office Use Only: Form Completed Date: __/__/____ Completed By (Initials):_____
DriveWealth, LLC 15 Exchange Place Jersey City, NJ 07302
support@DriveWealth.com FAX +1 973 998 5302
WR140901
