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

A-34—Model Form for Receipts for Dollar-to-Dollar Remittance Transfers (section 1005.31(b)(2))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345
Today’s Date: March 3, 2014
RECEIPT
SENDER:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
301-555-1212
RECIPIENT:
Carlos Gomez
106 Calle XXX
Mexico City
Mexico
PICK-UP LOCATION:
ABC Company
65 Avenida YYY
Mexico City
Mexico
Confirmation Code: ABC 123 DEF 456
Date Available: March 4, 2014
Transfer Amount: $100.00
Transfer Fees: +$7.00
Transfer Taxes: +$3.00
Total: $110.00
Transfer Amount: $100.00
Other Fees: -$4.00
Total to Recipient: $96.00
Recipient may receive less due to fees charged by the recipient’s bank and foreign taxes.
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

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