Revised 01-01-2015
Outgoing Wire Transfer
ABOUT WIRE TRANSFERS
KS StateBank only completes wire transfers for its clients. To be processed the same day, domestic transfer requests must be received by 3 p.m.
(CST) and international transfer requests must be received by 2 p.m. (CST). These deadlines may be earlier on Federal holidays. Requests
received after that time will be processed effective the next business day.
CLIENT (REQUESTOR) INFORMATION
Wire Date Client Name
Phone Number Requestor
Account Number Address
City State Zip
Wire Amount (Funds are transferred in $ U.S. unless otherwise directed.) Fee
DOMESTIC WIRE TRANSFER – BENEFICIARY BANK INFORMATION
Routing Number Bank Name
City State Zip
INTERNATIONAL WIRE TRANSFER – BENEFICIARY BANK INFORMATION
Swift Code Bank Name
Address (Required)
BENEFICIARY (RECIPIENT) INFORMATION
Name
Account Number Address (Required on International wire transfers.)
City State Zip
Additional Information
AGREEMENT
I represent I have the authority to make this wire transfer request on behalf of the account holder and from the account entered above. I authorize KS StateBank (“Bank”) to honor this
request to wire transfer funds from such account, and the Bank may rely in good faith on the information I have entered on this form. I acknowledge the Bank may take such actions it
deems appropriate to verify this request, and may at its sole discretion decline to accept this request and perform the wire transfer. I acknowledge and agree the Bank shall not be liable for
any loss or expense arising from the Bank’s actions regarding this request, and the Bank’s records shall be binding on all parties. I agree to pay the fees charged to such account in
accordance with Bank’s fee schedule.
Signature or Wire PIN Date
FOR OFFICE USE ONLY
Available Funds OFAC Check PIN Verification Call Back
TO SUBMIT
This request may be presented at any KS
StateBank office or mailed to KS StateBank,
Received By Date Time Received Date
Wire Transfer Department,
1010 Westloop Place, Manhattan, KS 66502.
Sent By Date Verified By Date
KS StateBank | 1010 Westloop Place | Manhattan, KS 66502