FORM IG210

v er s i on 03/2019

WI R E T R A N S F E R I N S T R U C T I O N S U SD

Date:
1 DD / MM / YYYY
Banking Institution’s Name:

Account Officer:

Name of Account holder, as it appears on Bank records:

2
Account Number: Amount to Transfer:

SWIFT Code: ABA Number:

IBAN Number: Sort Code:

I hereby authorize you to debit my account and wire the debited amount to the account listed below. Please wire the full amount, net of all fees.

3 USD ($)
Beneficiary Name:
ITA International Financial Services Corp.
268 Ave. Ponce de León, Suite 1406
Hato Rey, San Juan
Puerto Rico, 00918
Account Number: 215001486
Beneficiary Bank:
HSBC Bank
452 Fifth Avenue New York, NY
United States
SWIFT# MRMDUS33XXX

For further credit to (Plan Participant’s Name):

Plan Number:

*Please be aware that the Intermediary Bank may charge a wire fee, which should be paid by the sender. In order to avoid any wire shortage, please consult your sender bank to find out the current wire fee charged by the Intermediary Bank.
The amount of wire transfer should be sent net of any wire transfer fees.

Account Holder’s Printed Name:

4

Account Holder’s Signature:

Copyright © 2017 ITA International Holdings, LLC. All rights reserved.

Investors Trust is a licensed trademark of ITA International Holdings, LLC.