Ukrainian Selfreliance Michigan Federal Credit Union 26791 Ryan Road, Warren, MI 48091 Phone: 586-756-3300 – Fax: 586-756-4316 – email: [email protected]

Member Wire Transfer Request to UKREXIM Bank Proxann] pro Peresylku Hro‘ej na Ukra\nu Requested by Date Osoba ]ka perekazu= hro‘i Data Amount Debit Account Suma Nomer raxunku z ]koho robyt/s] perekaz I hereby authorize Ukrainian Selfreliance Michigan Federal Credit Union to transfer funds to Ukraine per the following instructions: Cym ] doru;a[ Ukra\ns/kij Mi;igans/kij Federal/nij Kooperatyvi perekazaty vyqevkazanu sumu za adreso[ : First Name Father’s First Name Last Name Im’] Po bat/kovi Prizvyqe Street Name and Building/Apartment Number Nazva vulyci ta nomer budynku pome‘kann] Oblast Region Oblast/ Rajon Village City Selo Misto Country Zip Code Kra\na Po‘tovyj Indeks Passport Number Account Number Nomer Pasportu Nomer Raxunku v Banku Telephone Number Nomer telefonu Funds are routed to Kyiv and transferred to one of the branch cities: (please check to which city the final transfer is to be made) Bud/laska, vkawit/ do ]koho z nyw;e pere;yslenyx mist robyt/s] perekaz :

Armyansk Ivano-Frankivsk Luhansk Shostka

Berdychiv Izmail Lutsk Simferopol

Berehovo Kalush Lviv Storozhynets

Brody Kamyanets-Podilsk. Mariupol Sumy

Cherkasy Kharkiv Melitopol Ternopil

Chernivtsi Kherson Mukachevo Truskavets

Chernihiv Khmelnytskyj Mykolaiv Tyachiv

Chortkiv Kirovohrad Netishyn Uzhhorod

Chervonozavodske Korostyshiv Nova Kakhovka Vinnytsa

Chuhuiv Kramatorsk Novoselytsya Voznesensk

Dnipropetrovsk Kremenchuk Odesa Yalta

Donetsk Kryvyj Rih Poltava Yavoriv

Drohobych Kyiv Rivne Zaporizzhya

Illichivsk Lysychansk Sarny Zhytomyr

US Wire Transfer Fee: $ 25.00 Ukrainian Bank Fee: $ Komisijnyj zbir Kooperatyvy Samopomi; Komisijnyj zbir Ukra\ns/koho Banku - 1.5% (subject to change)

USMFCU Staff Signature Sign Here USMFCU Member Signature

Date Sent Verification Number Office Use Only:

WTR Number Sequence Number

Warren