Grant Wire Transfer Request
1. Nonprofit Information
Organization Name
EIN (Tax ID)
Contact Name
Contact Email
Contact Phone
2. Grant Details
Grant Name / Reference
Amount Requested (USD)
Purpose of Funds
3. Recipient Bank Information
Bank Name
Bank Address
Account Name
Account Number
Routing Number (ABA/SWIFT/IBAN)
Bank Country
Additional Notes
4. Authorization
Authorized Representative Name
Title
Signature
Date