WIRE INSTRUCTIONS 05/30/2019

ALL FUNDS ARE WIRED IN USD

Due to the nature of individual hand-writing and the need for absolute accuracy, enter the information electronically.

Information Requested Provide Information Below Notes for timely wire transfer
Leave as "ALL GRANTS" unless unique instructions are
Foundation Grant Number (OPP): ALL GRANTS required for individual grants. In that case, enter the
OPP ID (grant number).

Legal Name of Grantee Organization:

Name of Account Holder Organization: Must match Name of Grantee or explain below.

If Legal Name of Grantee and Account

Holder do not match, explanation
required:

Bank Information
Name:

Street Address:

City:
State:
Zip:
Country:

Account Information
SWIFT Code Wire ABA Number should be 9 numbers
(Wire ABA Number for US Banks): SWIFT Code should be 8 or 11 characters

Account Number (IBAN for EU):

For Further Credit (FFC) Information (provide only AS NECESSARY)

Name of Account Holder Organization:

Account Number (if required):

Intermediary (Correspondent) Bank Information (provide only AS NECESSARY)

Bank Name:
Bank Country:
Intermediary Account Name:
SWIFT Code Wire ABA Number should be 9 numbers
(Wire ABA Number for US Banks): SWIFT Code should be 8 or 11 characters
Account Number (IBAN for EU):

Authorized Financial Contact Information

Authorized Financial Contact Name /
Title:
Phone Number:
Email:
Date (MM/DD/YYYY):

Financial Contact Signature:

The grantee named above (the “Grantee”) acknowledges it will receive payment from (the “Foundation”) by wire transfer to the account listed above. I certify that I am an
authorized financial representative of the Grantee and that I have the authority to authorize receipt of payment on the Grantee's behalf. The Grantee agrees to hold the Foundation
harmless, and agrees to reimburse the Foundation for all penalties and fees incurred as a result of any delay or failure by the Grantee to receive payment caused by any inaccuracy,
ambiguity or omission of any kind whatsoever in the bank account data submitted by the Grantee above. This authorization will remain in full force and effect until the Grantee or
Foundation has received written notice of its termination from the terminating party in such time and manner as to afford the other party and financial institution(s) a reasonable
opportunity to act upon said termination request.

Return this form via email to:

the exact sender