Individual Name:
Individual ID No.:

Amount:		Receiving Bank Acct. No.:
Receiving Bank ID:		Card Transaction Type:
Reference Info #1:		Reference Info #2:
Terminal ID Code:		Transaction Serial No.:
Transaction Month:		Transaction Day:
Authorization Code:		Terminal Location:
Terminal City:		Terminal State:
:Last Transfer Date:		Create Prenote:
Hold Transfer:		Prenote Date: