Ukrainian Selfreliance Michigan Federal Credit Union 26791 Ryan Road, Warren, MI 48091 Phone: 586-756-3300 – Fax: 586-756-4316 – email: [email protected] Form #030114 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 Currency Type 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 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 Drohobych Kramatorsk Netishyn Truskavets Berdychiv Illichivsk Kremenchuk Novoselytsya Tyachiv Berehovo Ivano-Frankivsk Kryvyj Rih Odesa Uzhhorod Brody Izmail Kyiv Poltava Vinnytsa Cherkasy Kalush Lysychansk Rivne Voznesensk Chernivtsi Kamyanets-Podilsk. Luhansk Sarny Yalta Chernihiv Kharkiv Lutsk Shostka Yavoriv Chortkiv Kherson Lviv Simferopol Zaporizzhya

Chuhuiv Khmelnytskyj Mariupol Storozhynets Zhytomyr Dnipropetrovsk Kirovohrad Mukachevo Sumy Donetsk Korostyshiv Mykolaiv Ternopil

US Wire Transfer Fee: $ 35.00 Purpose: Komisijnyj zbir Kooperatyvy Samopomi; Receiving bank determines their fee Call back phone number required for verification.

USMFCU Staff Signature Sign Here USMFCU Member Signature

Date Sent Office Use Only:

Warren

By signing above, I hereby request that Ukrainian Selfreliance Michigan Federal Credit Union perform the funds transfer described above. I understand and agree that this funds transaction is subject to USMFCU’s Funds Transfer Agreement and Disclosure and schedule of fees and charges.