Incoming Department Wire/ACH Form

Check one:

Foreign:

Domestic:

(Required)

Customer Information

(This is who is sending the wire.)

Name:

Address:

City, State:

Country :

Bank Name:

Communication Date:
	(This is the date you communicated the amount due and bank information to the payee/customer)

Acccounting Details

Dollar Amount:
	(Please use commas and a decimal point ex. $1,000,000.00)
Check one:	Exact Amount:	Estimated Amount:
Fund: Acct: UDDS: Class:
Accts Rec Invoice No. (GAR): (if applicable)
Department Invoice No.: (if applicable)

Your Information

Name:

Department:

Phone:

Please enter as (###) ###-####

Fax:

Please enter as (###) ###-####

Email:

Comments:

University of Wisconsin-Madison