EFTA01434373.pdf

1 First Bank Transfer Application FOR BANK USE ONLY BRANCH NO. PREFIX TEST KEY DATE TIME TRANSFER TYPE: H WIRE n CABLE ❑ DRAFT n Mail to Customer r—1 Mail to Payee f—1 Send to Branch REP SIGNATURES (Complete appropriate boxes); KEY MODIFY MODIFY APPROVE IF TRANSFERRING FOREIGN CURRENCY: CONTRACT NO VALUE DATE CONVERSION RATE CONVERTED BY (Initials) TRANSFER AMOUNT (FOR BANK USE ONLY) FOREIGN CURRENCY (Type and Amount) TRADER'S NAME 52,500.00 U.S. DOLURS NOTE: • Foreign currency amount multiplied by the exchange rate = U.S. dollar Amount. * U.S. Dollar amount divided by the exchange rate = Foreign Cunency Miount. ADDITIONAL FEES TOTALAMOUNT METHOD OF PAYMENT; INTERMEDIARY CORRESPONDENT BANK: (If necessary) DEBIT ACCOUNT NO. DEBIT BRANCH/DEPT. NO. 717 ABA ROUTING NOJSWIFT CODE 717-1-018893 NAME/ACCOUNT TITLE J. Epstein Virgin Islands Foundation EFTA01434373 BANK NAME MAILING ADDRESS: ADDRESS 6100 RED HOOK QTR. B3 PHYSICAL ADDRESS: SAME CITY, STATE, ZIP CODE, COUNTRY CITY, STATE, ZIP CODE, COUNTRY ST. THOMAS. VI, 00802-1348, USA TO: PAYEE/BENEFICIARY'S BANK FOR: PAYEBACCOUNT OF ULTIMATE BENEFICIARY ACCOUNT NO. BANK CODE BANK NAME NAME/ACCOUNT TITLE J. Epstein Virgin Islands Foundation, Inc. DEUTSCHE BANK ADDRESS 345 Park Avenue ADDRESS 6100 RED HOOK QTR B3 CITY, STATE, ZIP CODE, COUNTRY CITY, STATE, ZIP CODE, COUNTRY ST. THOMAS, VI 00802 NEW YORK, NY 10154 ORIGINATOR REFERENCE: BENEFICIARY REFERENCE: SPECIAL INSTRUCTIONS: (Optional) THE UNDERSIGNED AGREES TO THE CONDITIONS ON THE REVERSE SIDE OF THIS APPLICATION. CUSTOMER'S TELEPHONE NO"›.-^ 9/2/2016 DATE OF APPLICATION: y ler's ^gnature Customers Signature ///AppfcabfeJ FOR BANK USE ONLY CUSTOMER'S TRANSFER REQUEST: (Complete appropriate boxes) ❑ FAX ❑ IN PERSON ❑ PHONE ❑ MAIIJMESSENGER I.D. USED (Do n<" leave blank) 1""! Teleohone/Fax agreement on file n One time only transaction n Hold placed ❑ CALL-BACK IF OVER $ LIMIT; ❑ fly I I Spoke to I I Time TAKEN IN BY (Print Name) INITIALS TEST KEY CALCULATED BY (If different than taken in by) INITIALS EFTA01434374 BRANCH AUTHORIZED SIGNER (Print Name) BRANCH TELEPHONE NO.: ( ) BRANCH AUTHORIZED SIGNATURE NNNN-2196-1206R Page 1 of 2 EFTA01434375