Model Form for
Pre-Payment Disclosures for Remittance Transfers Exchanged into Local
Currency
| 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 |
| Exchange Rate: |
US$1.00 = 12.27 MXN |
| Transfer Amount: |
1,227.00 MXN |
| Other Fees: |
-30.00 MXN |
| Total to Recipient: |
1,197.00 MXN |
Recipient may receive less due to foreign
taxes (Est. 10 MXN).
