Incoming Department Wire/ACH Form

Customer Information
(This is who is sending the wire.)

Name:

Address:

City, State:

Country:

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 or Estimated Amount
Dept: Fund: Prog: Project: Account:
Department Invoice No.: (if applicable)

Your Information

Name:

Department:

Phone:

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

Fax:

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

Email:

Comments:

Accounting Services