EFTA00614909.pdf

BAIWCO POPULAR. Ref. No. or Test Key -- Amount 2011102118219060 Commission Transmission 25.00 I 25.00 Branch Prefix and Name 193 VISUC MAIN BRANCH•193 IC0000.00 Outgoing Transfer of Funds Cuireney USD USD Equivalent lam Date 04M-DD-YTYY) 4 10 2014 Name TERRANCE E RABSATE-KAREN EL RABSATT Address I 6-E ESTATE NADIR piriglast ti City ST THOMAS Stale VIRGIN ISLANDS I !CENSE AND COUNTRY OF ORIGIN DOC15369 I VIRGIN ISI ANDS LI S and Comity or State Pay? to Rank Illadiciaret Hank, 4I04 To0CT n.4mv Address 25 PARK PLACE NE ATEA ceN-T-A-G-DO-R-0-I-A-1-.0-3.4--3 Intermediary Bank Address Iltneliciants Name FUEURE TECI1NOLOGIES VENTURE EEC Address 1C0 PE1TY ROAD SUITE B City LAVVRENCEVILLE Special Instructions Hame _ . TERRANCE E RAIJSA I AddresS ISE ESTATE NADIR Stale GEORGIA Rate 0.0 0.00 inossetion Total 100,050.00 Recurring ID Debit Account 695201088 Business I Profession / Occupation SELF EMPLOYED Country VIRGIN ISLANDS, U.S. I Acenunt Account Nlmberor IBAN IT) 1009112552665 • COurary ZipCode 03802 Expiration Date 20.11/1:2015 Expiration Date I ARA SWIFT Cork (Route and Transit Number) 061000104 non or s to- t oue (Route and Transit Numbs") Zip Code 3.0043 No* by Telephone Authorized PersonMaTormation ' Business / Profession /Occupation SELF EMPLOYED C4Y ST THOMAS Slaw VIRGIN ISLANDS Count.) VIRGIN ISLANDS, U S. ID Type. Number and Country or State LICENSE AND COUNTRY OF ORIGIN I DDC35369 j VIRGIN ISLANDS. U.S. ype. mintier and Country (wire I I Address City ID Type, Number and Caedr) Of Stale ID Type, Number and Caney or Sale _ Putpose of Tams-setae, PMT FOR PURCHASE 7.ip Code 00902 Expiration flute 20,JUL 2015 Espinnon Date of the Person Placing_thoprdes.. Business / Profession tax:upsilon Stale Country Lip Code Expiration Date Esau:Atm Uwe Personal, Fami y. . Wc catify the verification of the ourocuo of the raiment in order to determine that it Household Remittance is net prohibited by any applicably regulation or Policy. SignaturMs) of PersoNs, Piecing the Order RequiredSignattrtn. ) 'LA r t/i 2Lz . c' r i v ut er. 1 Ku tbrik.... Summon. P BRA404 t 4.0 II) Employee No 0iCtis Signature& No. for Lenvapabk Fusels Autheneation Approving Officer's Signature BANK /CUSTOMER V/18219 EFTA00614909