Domestic /
Wire Transfer Payment Form / For office use only:
Grant ID:
Dollar Amt:
Fund:
This form must be filled out COMPLETELY by organizations requesting payments by wire transfer. Required information is noted with an asterisk.
If you have questions about this information, please consult your local bank.
1.Your Organization’s Information (This is the ultimate recipient of the wire transfer funds.)
*Grantee Organization Name*Grantee Organization Bank Account Name (If this differs from the Grantee Organization Name, please see Notes and provide an explanation in Section #4 or an official letter)
*Grantee Organization Account Number, Mexican CLABE # or the International Bank Account Number (IBAN) where applicable (see Notes):
*Grantee OrganizationMailing Address (A physical address is required for wires outside the US.)
2.Information About the Local Bank(This is the financial institution where your organization maintains its account.)
*Local Bank Routing/ABA or SWIFT Bank Identifier Code (SWIFT BIC) / *International Routing Code (IRC)(see Notes)*Local Bank Name
*Local Bank Address, City, State, Zip, Country
Additional information for Local Bank (wires to Indian banks require the Indian Financial System Code [IFSC]to ensure correct payment.)
3.Optional Intermediary Bank Information(This is a financial institution that the wire must pass through before reaching thelocal bank for int’l orgs ONLY).
Intermediary Bank Routing/ABA or SWIFT BIC / International Routing Code (IRC)(see Notes)Intermediary Bank Name / Intermediary Bank Account No.
Intermediary Bank Address City, State, Zip, Country (optional information)
Information for Intermediary Bank
4. Explanation of Different Bank Account Name and/or Additional Comments(if more space is needed, please attach a separate sheet; please also see Notes below for situations that require an official letter)
5. Signature & Contact Information
My signature here indicates agreement to all of the information on this Wire Transfer Form.
Signature: / *Date:
Name: / Phone Number:
Title: / Email Address:
Notes:In general, Tides Foundation does not make payment to the account of an individual. If payment to an individual account is necessary, Tides requires a letter, on letterhead, from a leader at the organization (not the person the wire will be sent to) explaining the need as well as details about the relationship between the person receiving the funds and the organization.
IBAN is required for wires going to Andorra, Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, French Guinea, French Polynesia, Germany, Gibraltar, Greece, Guadeloupe, Hungary, Iceland, Ireland (Republic of), Isle of Man, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, Malta, Martinique, Monaco, Netherlands, New Caledonia, Norway, Poland, Portugal, Reunion Island, Romania, San Marion, Saudi Arabia, Serbia and Montenegro, Slovakia Republic, Slovenia, Spain, Sweden, Switzerland, Tunisia, Turkey and the United Kingdom.
International Routing Code is required for wires going to Australia, Austria, Canada, Germany, Greece, Hong Kong, India, Ireland, Italy, New Zealand, Portugal, Russia, South Africa, Spain, Switzerland, Turkey and the United Kingdom.
Revised September 2011