Bank Account Details for Overseas Residents - Department of ...
Bank Account Details for Overseas Residents - Department of ...
Bank Account Details for Overseas Residents - Department of ...
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D9197.3/10 (Page 2 <strong>of</strong> 2)<strong>Bank</strong> <strong>Account</strong> <strong>Details</strong><strong>for</strong> <strong>Overseas</strong> <strong>Residents</strong>Wire Payment via a USA bankPlease fill in the details below in BLOCK letters, and then ask your bank or financial institution to verify the in<strong>for</strong>mation you have supplied.Name <strong>of</strong> <strong>Bank</strong> or FinancialInstitutionAddress <strong>of</strong> <strong>Bank</strong> or FinancialInstitution BranchNumber/StreetTown/City/PostcodeCountrySWIFT <strong>Bank</strong> Identifier Code (BIC)<strong>Account</strong> NumberInternational <strong>Bank</strong> <strong>Account</strong> Number(IBAN)Name <strong>of</strong> <strong>Account</strong> HolderName <strong>of</strong> intermediary <strong>Bank</strong> in USAAddress <strong>of</strong> intermediary <strong>Bank</strong> inUSAPlease ask your bank or financial institution to complete the details belowNumber/StreetTown/City/PostcodeSWIFT <strong>Bank</strong> Identifier Code (BIC)<strong>Bank</strong> Sort Code/Routing code <strong>of</strong>intermediary <strong>Bank</strong> in USATo the <strong>Bank</strong>/Financial Institution<strong>Bank</strong>/Financial Institution StampNote: This is NOT the <strong>Bank</strong> Identifier Code (BIC).We confirm that the customer account can receive deposits by electronic means via theintermediary bank in the USA whose details are provided by us above.We verify that the account details <strong>of</strong> the customer are correct.Your statementYour signatureI have attached a copy <strong>of</strong> a bank document that shows my bank details, including myaccount number and the name(s) <strong>of</strong> the account holder(s).✍DateYour name (please print)DVA or DEFCARE File No. (if known)Your Contact <strong>Details</strong> (optional)Home phone numberEmail
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