INTERNAL TRANSFER REQUEST FORM
409 Silverside Rd, Suite 105
Wilmington, DE 19809

P. 800.555.9316
F. 302.385.5099
Banking Services Provided by
The Bancorp Bank,
MEMBER FDIC, EQUAL HOUSING LENDER
  PART 1: Authorization
I authorize The Bancorp HSA to process a funds transfer transaction according to the instructions below between the following The Bancorp HSA accounts.
Name on Donor Account: Date
Transfer From Account#: Transfer To Account#: Amount of Transfer:
Name on Recipient Account (Required when name does not match Donor Account):
Signature of Requestor: Telephone Number of Requestor:
For processing, mail or fax this request to:
The Bancorp HSA
409 Silverside Rd, Suite 105
Wilmington, DE 19809

Fax: 302.385.5099
  PART 2: Limitations
Customer transfer requests will be processed on the business day they are received except in the following instances:
  1. The transfer amount exceeds the available balance in the donor account,
  2. There is a status on the donor and/or the recipient account that prohibits us from processing the request,
  3. There is a discrepancy in the information you have provided that prohibits us from processing the request,
  4. A signature card or other documentation is not on file for the donor and/or recipient account,
  5. There is a failure of equipment or communications which prevents the Bank from processing your request,
  6. And/or we receive notification or believe that the transfer request is forged, altered, or unauthorized.
In the event that the accounts are not titled the same or ownership among the transferring accounts changes, you will indemnify us for any losses incurred as a result of any transaction you initiate between these accounts that is later returned or is reported unauthorized. If any transfer you initiate is found to be unverifiable or cannot be completed for other reasons, you agree to hold us harmless for any loss resulting from the incomplete transfer.

For Internal Use Only:
Verified by: ________
Completed by: ________
Approved by: ________