.

~Sc6tiabank

OUTGOING PAYMENT TRANSFER

BRANCH1AGENCY 1CORRESPONDENT

ADDRESS

PLEASE .
PAY 20

SENDER'SREFERENCENUMBER

account no

ORDERINGINSTITUTION

52

h
./

SENDER'SCORRESPONDENT

RECEIVER'SCORRESPONDENT
'54

INTERMEDIfRY INSTITUTION

ACCOUNT WITH INSTITUTION

57

BENEFICIARYINSTITUTION

Ii I;II:O&J

C1

n j(

271

'IJO

BENEFICIARYCUSTOMER. FUll NAME. FUll ADDRESS

.59

1I!.f ("

full name
full address

102

11m

()-f

iiv(

VI

S -J("'
...;,~
~

: ',"
Yj

'" (
"

-~~

rr
C Y Ac Ir '15

THI D PAUU5

IJC JI.' 0 0~ /9 " /' /7 CI /' 'I

---"r~..:...:...If__=~_~..,=_...,..:..._"
,O~'1'__V
__ '_...!(~~'__o(~

BENEFICIARYACCOUNT NUMBER

f-+

~~:'';~.

I
!.~
i-!(~, n
11.1/. m, '"IrS A 1
'"
,.'" 1Y TrJC.
j

~ ,
.;;

7/

REMITTANCE INFORMATION

-0

oed'::

_~-=

COURT GOVERNl.II: At AGE

O~ ~j::-I:''1'::'I' D<
(e) IN ORDERTO PRE'll: ' OR
ACTUAL OR POTE HAl. LOSS
C
EC.r rAAlJD ()Q CRt
At ACFACILITATEAN INVCSTlGATlQIo;
OF OR PROSCCUTlONfOR FRAUD MONEY LAUNOERINGOR
ANY OTHERCRIMINALACTMTY YOU AlSO CONSEI'lTAND AUTHORIZEUSTO SHAREyOU!!
INFORMATIONWITHINTHESCOTIA8ANKGROUPOFCOMPANIES
IT

o.-;:c-

if

O/'

suo- 1E:.:s.J

--""

WE MAY USE THIRD PARTY SERVICEPROVIDERSTO PROCESSTHIS PAYMENT TRANSfER

FOR US. SOME OF OUR SERVICE PROVIDERSARE LOCATED OUTSIDE THE COUNTRY
WHERETHE PAYMENT TRANSfERREQUESTORIGINATEDAND THESESERVICEPROVIDERS
ARE SUBJECT'TO FOREIGN LEGISLATION. YOU UNDERSTAND AND ACKNOWLEDGE
THAT LAW ENFORCEMENT AUTHORITIES ANDIOR GOVERNMENTAL AUTHORITIES
IN THESE JURISDICTIONS MAY, UNDER APPLICABLE LEGISLATION, ACCESS THE

70

~o:;;:::---------I

I-+D-E-T-A-Il-S ~O-F
-C-HA-R-G-E-S---~---------------::::;

71

I-+-------------------'----t-----.l-ib""'--"""i------i
SENDERTO RECEIVERINFORMAIrON

~~~~~~~~SN

N~~~~t~~,Cg:~~~EgF

I~J~~E~~:C~I:ENg:~C~~S~C~:~~:~~~

EMPLOYEES OR AGENTS SHALL IN ANY WAY BE LIABLE TO YOU fOR THE BREACH
OF ANY PRIVACY, SECRECYOR CONFIDENTIAUTY PROVISIONS OF ANY LAWS OR
REGULATIONS IN YOUR COUNTRY OR ELSEWHERE, YOU AGREE TO INDEMNIFY US
AND OUR RESPECTIVEOFFICERS, DIRECTORS. EMPLOYEES OR AGENTS AGAINST
ANY AND ALL LOSSES. COSTS. EXPENSES. ACTIONS. PROCEEDINGS. CLAIMS.
DAMAGES OR OTHER LIABILITIES ONCLUDING LEGAL FEESAND EXPENSES)ARISING
DIRECn Y OR INDIRECTLY. BY REASON OF SUCH DISCLOSURES BY US OR ANY OF
OUR RESPECTIVE AGENTS. SUCH INDEMNITY BEING IN ADDITION TO ANY
INDEMNITY WHICH MAY BE AVAILABLE AT LAW,

72

PHONE NO.
BANK LEGAL NAME

<

Jell

rJ I ,c. i;. I rf(

/
I')

j<

BRANCH ADDRESS
L-

Call back required

A J.

![j " /1 'J

...('

~I7"__('_='f~

""7""

0 yes '

no

tI(

J /' f..
? d
/?

tL(

ii ""{

/
11

If yes, Customer contacted

---'__

Management Officer
NB: Shaded areas correspond to the fields on the most commonly
4502914 (09/07)

1 BRANCH

Signing Number

used SWIFT templates.

2 CUSTOMER

-----------v

. Trademarks of The Bank of Nova Scotia. Trademarks used under licence and control of The Bank of Nova Scotia.

3 DEBIT TO CUSTOMER'S ACCOUNT (DESTROY IF NOT REQUIRED)

4 AUDIT