A-35 – Model Form for Combined Disclosures for Dollar-to-Dollar Remittance Transfers (§ 1005.31(b)(3))
1000
XYZ Avenue
Anytown, Anystate 12345
Today’s Date: March 3, 2013
SENDER: RECIPIENT:
Pat Jones Carlos Gomez
100 Anywhere Street 106 Calle XXX
Anytown, Anywhere 54321 Mexico City
301-555-1212 Mexico
PICK-UP LOCATION:
ABC Company
65 Avenida YYY
Mexico City
Mexico
Confirmation Code: ABC 123 DEF 456
Date Available: March 4, 2013
Transfer Amount: $100.00
Transfer Fees: +$7.00
Transfer Taxes: +$3.00
Total: $110.00
Transfer Amount: $100.00
Other Fees: -$4.00
Other Taxes: -$1.00
Total to Recipient: $95.00
You have a right to dispute errors in your transaction. If you think there is an error, contact us within 180 days at 800-123-4567 or www.abccompany.com. You can also contact us for a written explanation of your rights.
You can cancel for a full refund within 30 minutes of payment, unless the funds have been picked up or deposited.
For questions or complaints about ABC Company, contact:
State Regulatory Agency
800-111-2222
www.stateregulatoryagency.gov
Consumer Financial Protection Bureau
855-411-2372
855-729-2372 (TTY/TDD)
www.consumerfinance.gov
| File Type | application/msword |
| Author | V. Wong |
| Last Modified By | Mandie Aubrey |
| File Modified | 2012-01-11 |
| File Created | 2012-01-11 |