Effective August 11, 2005, __________________________________________________________,
a financial institution operating in Florida, agrees to voluntarily waive the wire-transfer or processing
fees to our customers for wire-transfer payments for Holocaust-related reparations or restitution. 
Upon receipt of a written request and reasonable documentation from our customers, we will waive
all of our fees associated with processing these wire-transfer payments.

Name of Institution (please print)_____________________________________________________

Signatory (please print):___________________________________________________________

Title (please print):________________________________________________________________

Signature: ______________________________________________________________________

Contact Telephone Number:________________________________________________________

Information to be posted on FLDFS Website:
(please print)     

Name of Financial Institution                

___________________________________________________________________________________

Address for Sending Written Requests:            

__________________________________________________________________________________ 

City______________________________State__________________Zip_____________________

Contact Telephone Number for Questions (preferably toll-free):       

_________________________________________

Send this form to:         

Lynn Grossman
Florida Department of Financial Services
200 E. Gaines Street
Room 624G
Tallahassee, Fl 32399-4205
850-413-4160