Free Microsoft Word - 0752R Req for Disb of Registry Funds by Wire Trans 09_01.d. - Texas

County Auditor's Form #752R Harris County, Texas (09/01)

REQUEST FOR DISBURSEMENT OF REGISTRY FUNDS BY WIRE TRANSFER
CAUSE NO.

(Account name must be exactly as stated in the Court's Order. All payees must be listed on and sign this form.)

I/We (print name(s)), , request that the funds I am/we are to receive from the Court Registry be transferred by wire to my/our bank , ABA Number (9 digit checking or saving account wire ABA number): Account Number: Name on Account: I/We understand that I am/we are liable for any Incoming Wire Transfer fee my/our bank may charge.
Applicant Signature (As on Court Order and styling of bank account) Applicant Signature (As on Court Order and styling of bank account)

, , .

Date

Date

Applicant Signature (As on Court Order and styling of bank account)

Applicant Signature (As on Court Order and styling of bank account)

Date

Date NOTARY
(This section is required only if form is being submitted by mail without a copy of each applicant's driver's license or social security card)

THE STATE OF _____________________________§ COUNTY OF _______________________________§ Before me, ____________________________, a notary public, on this day personally appeared ______________________________
(Notary Public's Name) (Applicant(s) listed above)

_____________________________________________________________________________, known to me (or proved to me on the
(Applicant(s) listed above)

oath of ___________________________________) to be the person(s) whose name(s) is/are subscribed to the foregoing instrument and acknowledged to me that he/she/they executed the same for the purpose and consideration therein expressed. Given under my hand and seal of office this __________________ day of ________________________________, _______________. ______________________________________________________ ___________________________________________ NOTARY PUBLIC IN AND FOR THE STATE OF TEXAS (PRINT NAME) MY COMMISSION EXPIRES _________________________ County and District Clerk / County Auditor Use Only

Approximate Amount:
(Actual amount transferred from Registry may differ by interest earned from approval date to transfer date)

APPROVED:
County or District Clerk Date County Auditor Date