REG E - Electronic Funds Transfer (Institutions)

Pt. 1005, App. A

12 CFR Ch. X (1–1–16 Edition)

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APPENDIX A TO PART 1005—MODEL
DISCLOSURE CLAUSES AND FORMS
A–1—Model Clauses for Unsolicited Issuance
(§ 1005.5(b)(2))
A–2—Model Clauses for Initial Disclosures
(§ 1005.7(b))
A–3—Model Forms for Error Resolution Notice (§§ 1005.7(b)(10) and 1005.8(b))
A–4—Model Form for Service-Providing Institutions (§ 1005.14(b)(1)(ii))
A–5—Model Forms for Government Agencies
(§ 1005.15(d)(1) and (2))
A–6—Model Clauses for Authorizing OneTime Electronic Fund Transfers Using
Information From a Check (§ 1005.3(b)(2))
A–7—Model Clauses for Financial Institutions Offering Payroll Card Accounts
(§ 1005.18(c))
A–8—Model Clause for Electronic Collection
of Returned Item Fees (§ 1005.3(b)(3))
A–9—Model Consent Form for Overdraft
Services (§ 1005.17)

A–10 through A–30 [Reserved]
A–30(a)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency including a
disclaimer where non-covered third-party
fees and foreign taxes may apply
(§ 1005.31(b)(1))
A–30(b) —Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency including a
disclaimer with estimate for non-covered
third-party
fees
(§ 1005.31(b)(1)
and
§ 1005.32(b)(3))
A–30(c)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency including a
disclaimer with estimate for foreign taxes
(§ 1005.31(b)(1) and § 1005.32(b)(3))
A–30(d)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency, including a
disclaimer with estimates for non-covered
third-party
fees
and
foreign
taxes
(§ 1005.31(b)(1) and § 1005.32(b)(3))
A–31—Model Form for Receipts for Remittance Transfers Exchanged into Local Currency (§ 1005.31(b)(2))
A–32—Model Form for Combined Disclosures
for Remittance Transfers Exchanged into
Local Currency (§ 1005.31(b)(3))
A–34—Model Form for Receipts for Dollar-toDollar
Remittance
Transfers
(§ 1005.31(b)(2))
A–35—Model Form for Combined Disclosures
for Dollar-to-Dollar Remittance Transfers
(§ 1005.31(b)(3))
A–36—Model Form for Error Resolution and
Cancellation
Disclosures
(Long)
(§ 1005.31(b)(4))
A–37—Model Form for Error Resolution and
Cancellation
Disclosures
(Short)
(§ 1005.31(b)(2)(iv) and (b)(2)(vi))
A–39—Model Form for Receipts for Remittance Transfers Exchanged into Local Currency—Spanish (§ 1005.31(b)(2))
A–40—Model Form for Combined Disclosures
for Remittance Transfers Exchanged into
Local Currency—Spanish (§ 1005.31(b)(3))
A–41—Model Form for Error Resolution and
Cancellation Disclosures (Long)—Spanish
(§ 1005.31(b)(4))
A–1—MODEL CLAUSES FOR UNSOLICITED
ISSUANCE (§ 1005.5(b)(2))
(a) Accounts using cards. You cannot use
the enclosed card to transfer money into or
out of your account until we have validated
it. If you do not want to use the card, please
(destroy it at once by cutting it in half).
[Financial institution may add validation
instructions here.]
(b) Accounts using codes. You cannot use
the enclosed code to transfer money into or
out of your account until we have validated
it. If you do not want to use the code, please
(destroy this notice at once).

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Bur. of Consumer Financial Protection

Pt. 1005, App. A

[Financial institution may add validation
instructions here.]

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A–2—MODEL CLAUSES FOR INITIAL
DISCLOSURES (§ 1005.7(b))
(a) Consumer Liability (§ 1005.7(b)(1)).
(Tell us AT ONCE if you believe your
[card] [code] has been lost or stolen, or if you
believe that an electronic fund transfer has
been made without your permission using information from your check. Telephoning is
the best way of keeping your possible losses
down. You could lose all the money in your
account (plus your maximum overdraft line
of credit). If you tell us within 2 business
days after you learn of the loss or theft of
your [card] [code], you can lose no more than
$50 if someone used your [card][code] without
your permission.)
If you do NOT tell us within 2 business
days after you learn of the loss or theft of
your [card] [code], and we can prove we could
have stopped someone from using your [card]
[code] without your permission if you had
told us, you could lose as much as $500.
Also, if your statement shows transfers
that you did not make, including those made
by card, code or other means, tell us at once.
If you do not tell us within 60 days after the
statement was mailed to you, you may not
get back any money you lost after the 60
days if we can prove that we could have
stopped someone from taking the money if
you had told us in time. If a good reason
(such as a long trip or a hospital stay) kept
you from telling us, we will extend the time
periods.
(b) Contact in event of unauthorized transfer
(§ 1005.7(b)(2)). If you believe your [card]
[code] has been lost or stolen, call: [Telephone number] or write: [Name of person or
office to be notified] [Address].
You should also call the number or write
to the address listed above if you believe a
transfer has been made using the information from your check without your permission.
(c) Business days (§ 1005.7(b)(3)). For purposes of these disclosures, our business days
are (Monday through Friday) (Monday
through Saturday) (any day including Saturdays and Sundays). Holidays are (not) included.
(d)
Transfer
types
and
limitations
(§ 1005.7(b)(4)) (1) Account access. You may use
your [card][code] to:
(i) Withdraw cash from your [checking]
[or] [savings] account.
(ii) Make deposits to your [checking] [or]
[savings] account.
(iii) Transfer funds between your checking
and savings accounts whenever you request.
(iv) Pay for purchases at places that have
agreed to accept the [card] [code].
(v) Pay bills directly [by telephone] from
your [checking] [or] [savings] account in the
amounts and on the days you request.

Some of these services may not be available at all terminals.
(2) Electronic check conversion. You may authorize a merchant or other payee to make a
one-time electronic payment from your
checking account using information from
your check to:
(i) Pay for purchases.
(ii) Pay bills.
(3) Limitations on frequency of transfers. (i)
You may make only [insert number, e.g., 3]
cash withdrawals from our terminals each
[insert time period, e.g., week].
(ii) You can use your telephone bill-payment service to pay [insert number] bills
each [insert time period] [telephone call].
(iii) You can use our point-of-sale transfer
service for [insert number] transactions each
[insert time period].
(iv) For security reasons, there are limits
on the number of transfers you can make
using our [terminals] [telephone bill-payment service] [point-of-sale transfer service].
(4) Limitations on dollar amounts of transfers
(i) You may withdraw up to [insert dollar
amount] from our terminals each [insert
time period] time you use the [card] [code].
(ii) You may buy up to [insert dollar
amount] worth of goods or services each [insert time period] time you use the [card]
[code] in our point-of-sale transfer service.
(e) Fees (§ 1005.7(b)(5)) (1) Per transfer charge.
We will charge you [insert dollar amount] for
each transfer you make using our [automated teller machines] [telephone bill-payment service] [point-of-sale transfer service].
(2) Fixed charge. We will charge you [insert
dollar amount] each [insert time period] for
our [automated teller machine service] [telephone bill-payment service] [point-of-sale
transfer service].
(3) Average or minimum balance charge. We
will only charge you for using our [automated teller machines] [telephone bill-payment service] [point-of-sale transfer service]
if the [average] [minimum] balance in your
[checking account] [savings account] [accounts] falls below [insert dollar amount]. If
it does, we will charge you [insert dollar
amount] each [transfer] [insert time period].
(f) Confidentiality (§ 1005.7(b)(9)). We will
disclose information to third parties about
your account or the transfers you make:
(i) Where it is necessary for completing
transfers, or
(ii) In order to verify the existence and
condition of your account for a third party,
such as a credit bureau or merchant, or
(iii) In order to comply with government
agency or court orders, or
(iv) If you give us your written permission.
(g) Documentation (§ 1005.7(b)(6)) (1) Terminal
transfers. You can get a receipt at the time
you make any transfer to or from your account using one of our [automated teller machines] [or] [point-of-sale terminals].

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Pt. 1005, App. A

12 CFR Ch. X (1–1–16 Edition)

(2) Preauthorized credits. If you have arranged to have direct deposits made to your
account at least once every 60 days from the
same person or company, (we will let you
know if the deposit is [not] made.) [the person or company making the deposit will tell
you every time they send us the money] [you
can call us at (insert telephone number) to
find out whether or not the deposit has been
made].
(3) Periodic statements. You will get a
[monthly] [quarterly] account statement
(unless there are no transfers in a particular
month. In any case you will get the statement at least quarterly).
(4) Passbook account where the only possible
electronic fund transfers are preauthorized credits. If you bring your passbook to us, we will
record any electronic deposits that were
made to your account since the last time
you brought in your passbook.
(h) Preauthorized payments (§ 1005.7(b) (6), (7)
and (8); § 1005.10(d)) (1) Right to stop payment
and procedure for doing so. If you have told us
in advance to make regular payments out of
your account, you can stop any of these payments. Here’s how:
Call us at [insert telephone number], or
write us at [insert address], in time for us to
receive your request 3 business days or more
before the payment is scheduled to be made.
If you call, we may also require you to put
your request in writing and get it to us within 14 days after you call. (We will charge you
[insert amount] for each stop-payment order
you give.)
(2) Notice of varying amounts. If these regular payments may vary in amount, [we]
[the person you are going to pay] will tell
you, 10 days before each payment, when it
will be made and how much it will be. (You
may choose instead to get this notice only
when the payment would differ by more than
a certain amount from the previous payment, or when the amount would fall outside
certain limits that you set.)
(3) Liability for failure to stop payment of
preauthorized transfer. If you order us to stop
one of these payments 3 business days or
more before the transfer is scheduled, and we
do not do so, we will be liable for your losses
or damages.
(i)
Financial
institution’s
liability
(§ 1005.7(b)(8)). If we do not complete a transfer to or from your account on time or in the
correct amount according to our agreement
with you, we will be liable for your losses or
damages. However, there are some exceptions. We will not be liable, for instance:
(1) If, through no fault of ours, you do not
have enough money in your account to make
the transfer.
(2) If the transfer would go over the credit
limit on your overdraft line.
(3) If the automated teller machine where
you are making the transfer does not have
enough cash.

(4) If the [terminal] [system] was not working properly and you knew about the breakdown when you started the transfer.
(5) If circumstances beyond our control
(such as fire or flood) prevent the transfer,
despite reasonable precautions that we have
taken.
(6) There may be other exceptions stated in
our agreement with you.
(j) ATM fees (§ 1005.7(b)(11)). When you use
an ATM not owned by us, you may be
charged a fee by the ATM operator [or any
network used] (and you may be charged a fee
for a balance inquiry even if you do not complete a fund transfer).
A–3—MODEL FORMS FOR ERROR RESOLUTION
NOTICE (§§ 1005.7(b)(10) AND 1005.8(b))
(a) Initial and annual error resolution notice
(§§ 1005.7(b)(10) and 1005.8(b)).
In Case of Errors or Questions About Your
Electronic Transfers Telephone us at [insert
telephone number] Write us at [insert address] [or email us at [insert email address]]
as soon as you can, if you think your statement or receipt is wrong or if you need more
information about a transfer listed on the
statement or receipt. We must hear from you
no later than 60 days after we sent the
FIRST statement on which the problem or
error appeared.
(1) Tell us your name and account number
(if any).
(2) Describe the error or the transfer you
are unsure about, and explain as clearly as
you can why you believe it is an error or why
you need more information.
(3) Tell us the dollar amount of the suspected error.
If you tell us orally, we may require that
you send us your complaint or question in
writing within 10 business days.
We will determine whether an error occurred within 10 business days after we hear
from you and will correct any error promptly. If we need more time, however, we may
take up to 45 days to investigate your complaint or question. If we decide to do this, we
will credit your account within 10 business
days for the amount you think is in error, so
that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not
receive it within 10 business days, we may
not credit your account.
For errors involving new accounts, pointof-sale, or foreign-initiated transactions, we
may take up to 90 days to investigate your
complaint or question. For new accounts, we
may take up to 20 business days to credit
your account for the amount you think is in
error.
We will tell you the results within three
business days after completing our investigation. If we decide that there was no error, we
will send you a written explanation. You

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may ask for copies of the documents that we
used in our investigation.
(b) Error resolution notice on periodic statements (§ 1005.8(b)).
In Case of Errors or Questions About Your
Electronic Transfers Telephone us at [insert
telephone number] or Write us at [insert address] as soon as you can, if you think your
statement or receipt is wrong or if you need
more information about a transfer on the
statement or receipt. We must hear from you
no later than 60 days after we sent you the
FIRST statement on which the error or problem appeared.
(1) Tell us your name and account number
(if any).
(2) Describe the error or the transfer you
are unsure about, and explain as clearly as
you can why you believe it is an error or why
you need more information.
(3) Tell us the dollar amount of the suspected error.
We will investigate your complaint and
will correct any error promptly. If we take
more than 10 business days to do this, we
will credit your account for the amount you
think is in error, so that you will have the
use of the money during the time it takes us
to complete our investigation.

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A–4—MODEL FORM FOR SERVICE-PROVIDING
INSTITUTIONS (§ 1005.14(b)(1)(ii))
ALL
QUESTIONS
ABOUT
TRANSACTIONS MADE WITH YOUR (NAME OF
CARD) CARD MUST BE DIRECTED TO US
(NAME OF SERVICE PROVIDER), AND NOT
TO THE BANK OR OTHER FINANCIAL INSTITUTION WHERE YOU HAVE YOUR ACCOUNT. We are responsible for the [name of
service] service and for resolving any errors
in transactions made with your [name of
card] card.
We will not send you a periodic statement
listing transactions that you make using
your [name of card] card. The transactions
will appear only on the statement issued by
your bank or other financial institution.
SAVE THE RECEIPTS YOU ARE GIVEN
WHEN YOU USE YOUR [NAME OF CARD]
CARD, AND CHECK THEM AGAINST THE
ACCOUNT STATEMENT YOU RECEIVE
FROM YOUR BANK OR OTHER FINANCIAL
INSTITUTION. If you have any questions
about one of these transactions, call or write
us at [telephone number and address] [the
telephone number and address indicated
below].
IF YOUR [NAME OF CARD] CARD IS
LOST OR STOLEN, NOTIFY US AT ONCE
by calling or writing to us at [telephone
number and address].

A–5—MODEL FORMS FOR GOVERNMENT
AGENCIES (§ 1005.15(d)(1) AND (2))
(a) Disclosure by government agencies of information about obtaining account balances and
account histories (§ 1005.15(d)(1)(i) and (ii)).
You may obtain information about the
amount of benefits you have remaining by
calling [telephone number]. That information is also available [on the receipt you get
when you make a transfer with your card at
(an ATM)(a POS terminal)][when you make
a balance inquiry at an ATM][when you
make a balance inquiry at specified locations].
You also have the right to receive a written summary of transactions for the 60 days
preceding your request by calling [telephone
number]. [Optional: Or you may request the
summary by contacting your caseworker.]
(b) Disclosure of error resolution procedures
for government agencies that do not provide
periodic statements (§ 1005.15(d)(1)(iii) and
(d)(2)).
In Case of Errors or Questions About Your
Electronic Transfers Telephone us at [telephone number] Write us at [insert address]
[or email us at [insert email address]] as
soon as you can, if you think an error has occurred in your [EBT][agency’s name for program] account. We must hear from you no
later than 60 days after you learn of the
error. You will need to tell us:
• Your name and [case] [file] number.
• Why you believe there is an error, and
the dollar amount involved.
• Approximately when the error took
place.
If you tell us orally, we may require that
you send us your complaint or question in
writing within 10 business days.
We will determine whether an error occurred within 10 business days after we hear
from you and will correct any error promptly. If we need more time, however, we may
take up to 45 days to investigate your complaint or question. If we decide to do this, we
will credit your account within 10 business
days for the amount you think is in error, so
that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not
receive it within 10 business days, we may
not credit your account.
For errors involving new accounts, pointof-sale, or foreign-initiated transactions, we
may take up to 90 days to investigate your
complaint or question. For new accounts, we
may take up to 20 business days to credit
your account for the amount you think is in
error.
We will tell you the results within three
business days after completing our investigation. If we decide that there was no error, we
will send you a written explanation. You

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12 CFR Ch. X (1–1–16 Edition)

may ask for copies of the documents that we
used in our investigation.
If you need more information about our
error resolution procedures, call us at [telephone number][the telephone number shown
above].
A–6—MODEL CLAUSES FOR AUTHORIZING ONETIME ELECTRONIC FUND TRANSFERS USING
INFORMATION FROM A CHECK (§ 1005.3(b)(2))
(a) Notice About Electronic Check Conversion.
When you provide a check as payment, you
authorize us either to use information from
your check to make a one-time electronic
fund transfer from your account or to process the payment as a check transaction.
(b) Alternative Notice About Electronic Check
Conversion (Optional).
When you provide a check as payment, you
authorize us to use information from your
check to make a one-time electronic fund
transfer from your account. In certain circumstances, such as for technical or processing reasons, we may process your payment as a check transaction.
[Specify other circumstances (at payee’s option).]
(c) Notice For Providing Additional Information About Electronic Check Conversion.
When we use information from your check
to make an electronic fund transfer, funds
may be withdrawn from your account as
soon as the same day [you make] [we receive] your payment[, and you will not receive your check back from your financial
institution].

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A–7—MODEL CLAUSES FOR FINANCIAL INSTITUTIONS OFFERING PAYROLL CARD ACCOUNTS
(§ 1005.18(c))
(a) Disclosure by financial institutions of information about obtaining account information
for payroll card accounts. § 1005.18(c)(1).
You may obtain information about the
amount of money you have remaining in
your payroll card account by calling [telephone number]. This information, along with
a 60-day history of account transactions, is
also available online at [internet address].
You also have the right to obtain a 60-day
written history of account transactions by
calling [telephone number], or by writing us
at [address].
(b) Disclosure of error-resolution procedures
for financial institutions that provide alternative means of obtaining payroll card account
information (§ 1005.18(c)(1)(ii) and (c)(2)).
In Case of Errors or Questions About Your
Payroll Card Account Telephone us at [telephone number] or Write us at [address] [or
email us at [email address]] as soon as you
can, if you think an error has occurred in
your payroll card account. We must allow

you to report an error until 60 days after the
earlier of the date you electronically access
your account, if the error could be viewed in
your electronic history, or the date we sent
the FIRST written history on which the
error appeared. You may request a written
history of your transactions at any time by
calling us at [telephone number] or writing
us at [address]. You will need to tell us:
Your name and [payroll card account]
number.
Why you believe there is an error, and the
dollar amount involved.
Approximately when the error took place.
If you tell us orally, we may require that
you send us your complaint or question in
writing within 10 business days.
We will determine whether an error occurred within 10 business days after we hear
from you and will correct any error promptly. If we need more time, however, we may
take up to 45 days to investigate your complaint or question. If we decide to do this, we
will credit your account within 10 business
days for the amount you think is in error, so
that you will have the money during the
time it takes us to complete our investigation. If we ask you to put your complaint or
question in writing and we do not receive it
within 10 business days, we may not credit
your account.
For errors involving new accounts, pointof-sale, or foreign-initiated transactions, we
may take up to 90 days to investigate your
complaint or question. For new accounts, we
may take up to 20 business days to credit
your account for the amount you think is in
error.
We will tell you the results within three
business days after completing our investigation. If we decide that there was no error, we
will send you a written explanation.
You may ask for copies of the documents
that we used in our investigation.
If you need more information about our
error-resolution procedures, call us at [telephone number] [the telephone number shown
above] [or visit [internet address]].
A–8—MODEL CLAUSE FOR ELECTRONIC COLLECTION
OF
RETURNED
ITEM
FEES
(§ 1005.3(b)(3))
If your payment is returned unpaid, you
authorize [us/name of person collecting the
fee electronically] to make a one-time electronic fund transfer from your account to
collect a fee of [$llll]. [If your payment
is returned unpaid, you authorize [us/name
of person collecting the fee electronically] to
make a one-time electronic fund transfer
from your account to collect a fee. The fee
will be determined [by]/[as follows]:

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A–30(a)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into
Local Currency (§ 1005.31(b)(1))

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A–30(b)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into
Local Currency (§ 1005.31(b)(1))

Bur. of Consumer Financial Protection

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A–30(c)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into
Local Currency (§ 1005.31(b)(1))

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A–30(d)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into
Local Currency (§ 1005.31(b)(1))

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A–31—Model Form for Receipts for Remittance Transfers Exchanged into Local Currency
(§ 1005.31(b)(2))

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A–32—Model Form for Combined Disclosures for Remittance Transfers Exchanged into Local
Currency (§ 1005.31(b)(3))

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A–33—Model Form for Pre-Payment Disclosures for Dollar-to-Dollar Remittance Transfers
(§ 1005.31(b)(1))

Bur. of Consumer Financial Protection

Pt. 1005, App. A

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A–34—Model Form for Receipts for Dollar-to-Dollar Remittance Transfers (§ 1005.31(b)(2))

Pt. 1005, App. A

12 CFR Ch. X (1–1–16 Edition)

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A–35—Model Form for Combined Disclosures for Dollar-to-Dollar Remittance Transfers
(§ 1005.31(b)(3))

Bur. of Consumer Financial Protection

Pt. 1005, App. A

A–36—Model Form for Error Resolution and Cancellation Disclosures (Long) (§ 1005.31(b)(4))

and

Cancellation

Disclosures

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A–37—Model Form for Error
(§ 1005.31(b)(2)(iv) and (b)(2)(vi))

Pt. 1005, App. A

12 CFR Ch. X (1–1–16 Edition)

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A–38—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into
Local Currency—Spanish (§ 1005.31(b)(1))

Bur. of Consumer Financial Protection

Pt. 1005, App. A

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A–39—Model Form for Receipts for Remittance Transfers Exchanged into Local Currency—
Spanish (§ 1005.31(b)(2))

12 CFR Ch. X (1–1–16 Edition)

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Pt. 1005, App. A

Bur. of Consumer Financial Protection

Pt. 1005, App. A

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A–40—Model Form for Combined Disclosures for Remittance Transfers Exchanged into Local
Currency—Spanish (§ 1005.31(b)(3))

Pt. 1005, App. C

12 CFR Ch. X (1–1–16 Edition)

A–41—Model Form for Error Resolution and Cancellation Disclosures (Long)—Spanish
(§ 1005.31(b)(4))

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[76 FR 81023, Dec. 27, 2011, as amended at 77 FR 6290, Feb. 7, 2012; 77 FR 40459, July 10, 2012;
78 FR 30705, May 22, 2013; 79 FR 55991, Sept. 18, 2014]