A-33—Model Form
for Pre-Payment Disclosures for Dollar-to-Dollar Remittance Transfers
(section 1005.31(b)(1))
| ABC Company |
| 1000 XYZ Avenue |
| Anytown, Anystate 12345 |
| Today’s Date: |
March 3, 2014 |
| NOT A RECEIPT |
| 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.
