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Generic Fee Waiver Forms for Financial Institutions

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 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