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 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 Ivano-Frankivsk Lysychansk Shostka Berdychiv Izmail Luhansk Simferopol Berehovo Kalush Lutsk Storozhynets Brody Kamyanets-Podilsk. Lviv Sumy Cherkasy Kharkiv Mariupol Ternopil Chernivtsi Kherson Mukachevo Truskavets Chernihiv Khmelnytskyj Mykolaiv Tyachiv Chortkiv Kirovohrad Netishyn Uzhhorod Chuhuiv Korostyshiv Novoselytsya Vinnytsa Dnipropetrovsk Kramatorsk Odesa Voznesensk Donetsk Kremenchuk Poltava Yalta Drohobych Kryvyj Rih Rivne Yavoriv Illichivsk Kyiv Sarny Zaporizzhya Zhytomyr US Wire Transfer Fee: $ 35.00 Purpose: Komisijnyj zbir Kooperatyvy Samopomi; Receiving bank determines their fee USMFCU Staff Signature Sign Here USMFCU Member Signature Date Sent Office Use Only: Warren .