11545 W. Touhy Avenue, Chicago, Illinois 60666 800-328-1935 www.alliantcreditunion.
org
Member Authorization for Wire Transfer form – Internet Request
1. 11 JAN 2024 SOURABH MOURYA 11 JAN 2024
date to be wired initial date
2. MEMBER INFORMATION (complete all sections)
Sourabh Mourya membership number 0026534258 Ph +1 240 900 0876
member name joint owner name (only if joint owner requests wire) account number
Sourabh Mourya Address: 124 B civil Lines Bareilly Savings Account 10100265342587 Ph +1 240 900 0876
member address (no p.o. box) daytime phone (where member may be reached if needed) (required)
3. AMOUNT OF WIRE $36000 o $25.00 domestic wire fee o $50.00 international wire fee
amount of wire
4. DESTINATION OF FUNDS
State bank of india
wire to (name of bank or credit union)
Rampur garden Bareilly UP 243001 India
address (required for international wires) city state/province zip/postal code country
SWIFT CODE : SBININBB852
receiving institution's 9-digit ABA # (for domestic wire transfer) swift/telex # or sort code (for international wire transfer)
FOR FURTHER CREDIT TO
Suman lall account number 38748597469
name of title or investment company or financial institution account number
110 B CIVIL LINES BAREILLY UP 243001 INDIA
address (required for all wires) (no p.o. box) city state/province zip/postal code country
FOR FINAL CREDIT TO
name on account account or escrow number (IBAN# also required for european
transfers – can be up to 34 characters)
address (required for all wires) (no p.o. box) city state/province zip/postal code country
attention/reference/special instructions
Please print this form, sign in the space below, and fax, along with a copy of a valid government-issued photo ID enlarged to 200% to
773-462-2095. You will be contacted by Alliant Credit Union to confirm this information prior to the wire going out.
signature
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