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
