Request for Domestic Electronic Funds Transfer
To avoid delays, please contact Richard Emrich, NU Treasury at 7-0422, or email or fax this completed
form to: r-emrich@northwestern.edu or Fax: (847) 467-4988. Items in red/bold are mandatory.
Today’s Date (if requested prior to 10am): _________________
Origin:  Financial Operations  Other ________________
Requested Transfer Date:
On or Before: ______________ (allow 24 hours)
Exactly on: _____________________
Requested Amount in USD: ________________________________ (please print clearly)
BENEFICIARY DETAILS: (Please type clearly and accurately to avoid delays)
Name of Person or Entity Receiving Funds: _______________________________________
Address: _____________________________________________________________________
Contact: _____________________________________________________________________
Contact Telephone Number:_____________________________________________________
Contact FAX Number:__________________________________________________________
Any Special Notes/ Instructions/ Reference: _______________________________________
____________________________________________________________________________
____________________________________________________________________________
BENEFICIARY BANK: (Please type clearly and accurately to avoid delay)
Bank Name: __________________________________________________________________
Bank Account Number: ________________________________________________________
Name On Account:____________________________________________________________
ABA Number:_________________________________________________________________
PURPOSE OF TRANSFER (brief explanation of need for funds):
______________________________________________________________________________
PERSON REQUESTING TRANSFER:
AUTHORIZING NAME:________________________________________________________
SIGNATURE: _________________________________________________________________
SEND CONFIRMATION TO: ___________________________________________________
ACCOUNTING TREATMENT:
CUFS or PeopleSoft GL Chartstring:______________________________________________
If ACH request – will this payment stay in the US or end up outside the US?_________________
If Wire transfer request – is this payee on the OFAC SDN list? ___________________________
*******************Treasury Only*********************
FedWire 
ACH 
Chase Model or Template Id: ________________
Northern Model or Template Id: ______________
Signature Specimen on File:  Yes
Authorization to Proceed:  Yes _____________
This Form and Backup given to Accounting Services:  Yes _______