Wire Request Form

To send money from your account at Healthcare FCU account, please complete, print, and sign this form.

For security reasons the following must be observed:

	All requests must be made IN WRITING, using this form.
	This form must have ORIGINAL SIGNATURES.
	The person requesting the wire must deliver this form IN PERSON to the credit union at 1126 MONTGOMERY DRIVE, Santa Rosa.

Note: The cut-off time is 12.00 p.m. (noon) Monday through Friday.

Wire to: Name of institution	ABA number (also known as a Routing number)
Credit to: Account name Account number	Account Holder's: Address City, State, Zip
Final credit: (If necessary) Account name Account number	Credit to: Address City, State, Zip
Amount: $	From your account at HFCU: Savings Checking Money Market
I hereby authorize Healthcare Federal Credit Union (HFCU) to initiate a transfer of funds in accordance with the information listed above. I understand the credit union will make a good faith effort to send the wire the same day the request is received. HFCU will not be responsible for delays beyond its control - including but not limited to wires returned due to incorrect information, system delays, or delays from the receiving institution late posting of the final credit. I understand my account will be debited $25 for the processing fee.
______________________________ Printed Name	______________________________ Signed Name

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