FUNDS TRANSFER APPLICATION AND AGREEMENT

WIRE INFORMATION
Branch / Department: Wire Purpose: USD Equivalent:

Value Date: Commission:

Delivery: q Email q Walk In Foreign Currency & Amount: Transmission Fee:

q Telephone q Fax q Letter Rate: USD Total Debit:

ORIGINATOR INFORMATION
Account Number: Telephone:
alejandro
Account Title:

Physical Address:

BENEFICIARY INFORMATION
Account Number: Account Title:

Physical Address: Occupation / Profession:

Payment Details:

BENEFICIARY BANK
Name: Routing Number (ABA): Swift Code:

Physical Address:

INTERMEDIARY BANK
Name: Routing Number (ABA): Swift Code:

Physical Address:

This transaction is subject to the attached Funds Transfer Terms and Conditions (Annex A).

Originator’s Signature Date

FOR BANK USE ONLY

We certify the originator’s signature was verified against bank’s record and found to be in conformity.

Prepared by Approved by
CALL BACK VERIFICATION
We certify that we verify that the Wire Transfer Agreement Submitted by telephone with Call Back Verification was on file at the moment of
the transaction and that security procedures were performed as describe in Bank’s Security Procedures.
Call Back to Telephone: Date:
Contact Person Name: Time:
Observations:

Call made by (Print name and employee no.): Signature:

2470 Fund Transfer Application Agreement

 Anejo A / Annex A

TRANSFERENCIA DE FONDOS – TERMINOS Y CONDICIONES

(FUNDS TRANSFER – TERMS AND CONDITIONS)

En esta transacción se aceptan los fondos únicamente bajo las siguientes condiciones a menos que expresa y especialmente se convenga lo
contrario por escrito:
In this transaction, the funds are accepted only under the following conditions unless otherwise expressly and specifically agreed to in writing:

• El Banco queda en libertad de valerse de, o sustituir a cualquier corresponsal, sus Agentes u otra Agencia cualquiera, pero en ningún
caso será responsable el Banco o cualquiera de sus corresponsales por las mutilaciones, interrupciones, omisiones, errores o
demoras que ocurran en el Correo o en las Compañías de Cables, Telégrafos y Telegrafía Inalámbrica o que sean causadas por
cualquier empleado de tales compañías o motivadas por cualquier causa que esté fuera del dominio del Banco o de sus
corresponsales; no siendo el Banco responsable de errores que se originen por error, negligencia o culpa de cualquier Corresponsal
Sub-Agente u otra Agencia cualquiera.
The Bank shall have the right to use, or substitute any correspondent, its Agents or any other Agency, but in no case shall the Bank
or any of its correspondents be responsible for the mutilation, interruptions, omissions, mistakes or delays that may occur at the Post
Office or at the Cable, Telegraph, or Wireless Telegraph Companies or that may be caused by any employee of such companies or
that result from any cause outside the control of the Bank or of its correspondent Sub-Agent; not being the Bank responsible for
errors originating from mistake, negligence or fault of any correspondent Sub-Agent or any other agency.

• Si así lo solicitare el cliente, el Banco hará los esfuerzos por restituir los fondos, pero esto únicamente después de que el Banco haya
recibido confirmación de la cancelación en firme de la remesa, y tratándose de fondos que hayan sido convertidos a moneda
extranjera, esta restitución se hará solamente al tipo de compra que rija el Banco en la fecha en que dicha restitución se efectúe.
If so requested by the client, the Bank will do the efforts to return the funds, but only after the Bank has received confirmation of the
firm cancellation of the remittance, and in the case of funds converted to foreign money, this return shall only be made at the
purchase rate in force at the Bank on the date that such return is effected.

• Autorizo a Oriental Bank (el Banco) a debitar de mi cuenta la cantidad indicada en el formulario de solicitud con el propósito de
realizar una transferencia de fondos de acuerdo a las instrucciones descritas anteriormente.
Hereby we authorize Oriental Bank (The Bank) to debit our account for the total amount indicated on the Funds Transfer
Application, for the sole purpose of making a funds transfer, following the instructions imparted by me to complete such
transaction.

• Confirmo que la cuenta y la información del beneficiario es la correcta.

We confirm that the said account and information, on behalf of the beneficiary, is correct.

• Certifico que he leído, entendido y aceptado los términos descritos en el formulario de Solicitud de Transferencias de Fondos.
We acknowledge that we have read, understood and accepted the terms and conditions on the Funds Transfer Application.

• Entiendo que los fondos deben estar disponibles en la cuenta a debitar al momento del Banco realizar la transferencia y de no ser
así no se podrá procesar la misma.
We acknowledge that the funds must be available on the account to be debited for the processing of the Funds Transfer at the very
moment that will be made and, if the funds are not available, the Bank will restrain for the delivery of such funds, until they are
available.

• Entiendo que soy responsable de los errores que puedan surgir de la información presentada en este formulario y que el horario
límite para solicitar el servicio y entregar la documentación requerida para procesar esta transferencia de fondos es hasta las
4:00pm. De lo contrario la misma podría procesarse con fecha del próximo día laborable.
We acknowledge that we are solely responsible of any error that may occur from the information given to process the funds
transfer in the Funds Transfer Application. All funds transfer will be processed until 4:00pm; if the Funds Transfer
Application is completed in all parts and handed prior to cut off hour. If the information is given after the cut off hour, it’ll be
processed the following bank day.

____________________________________
Firma Autorizada/Authorized Signature

2470 Fund Transfer Application Agreement