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G-10(A) Applications and Solicitations Model Form (Credit Cards)
Interest Rates and Interest Charges
Annual Percentage Rate
(APR) for Purchases

[Purchase rate]
[Description that rate varies and how it is determined, if applicable]

APR for Balance Transfers

[Balance transfer rate]
[Description that rate varies and how it is determined, if applicable]

APR for Cash Advances

[Cash advance rate]
[Description that rate varies and how it is determined, if applicable]

Penalty APR and When it
Applies

[Penalty rate]
[Description of events that may result in the penalty rate]
[Description of how long penalty rate may apply]

[How to Avoid Paying
Interest on Purchases/
Paying Interest]

[Description of grace period for purchases or statement that no grace period applies]

[Minimum Interest
Charge]/[Minimum
Charge]

[Description of minimum interest charge or minimum charge]

For Credit Card Tips from
the Federal Reserve
Board

[Reference to Board’s website]

Fees
[Annual Fee]/[Set-up and
Maintenance Fees]

[Notice of available credit, if applicable]
[Description of fees for availability or issuance of credit, such as an annual fee, if
applicable]

Transaction Fees
 Balance Transfer

[Description of balance transfer fee]

 Cash Advance

[Description of cash advance fee]

 Foreign Transaction

[Description of foreign transaction fee]

Penalty Fees
 Late Payment

[Description of late payment fee]

 Over-the-Credit Limit

[Description of over-the-credit limit fee]

 Returned Payment

[Description of returned payment fee]

Other Fees
 Required [insert name

of required insurance,
or debt cancellation or
suspension coverage]

[Description of cost of insurance, or debt cancellation or suspension plans] [Cross
reference to additional information, if applicable]

How We Will Calculate Your Balance: [Description of balance computation method]
Loss of Introductory APR: [Circumstances in which introductory rate may be revoked and rate that applies if introductory
rate is revoked, if applicable]
[Description that rate that applies after introductory rate is revoked varies and how it is
determined, if applicable]

G-18(G) Periodic Statement Form

Page 1 of 2

XXX Bank Credit Card Account Statement
Account Number XXXX XXXX XXXX XXXX
February 21, 2012 to March 22, 2012
Payment Information

Summary of Account Activity
Previous Balance
Payments
Other Credits
Purchases
Balance Transfers
Cash Advances
Past Due Amount
Fees Charged
Interest Charged

$80.52
-$50.00
+$0.00
+$52.13
+$0.00
+$0.00
+$0.00
+$37.00
+$0.00

New Balance

$119.65

Credit limit
Available credit
Statement closing date
Days in billing cycle

$2,000.00
$1,880.35
3/22/2012
30

New Balance

$119.65

Minimum Payment Due

$10.00

Payment Due Date

4/20/12

Late Payment Warning: If we do not receive your
minimum payment by the date listed above, you may have
to pay a $35 late fee and your APRs may be increased up
to the Penalty APR of 28.99%.
Minimum Payment Warning: If you make only the minimum
payment on time each month and no other amounts are
added to the balance, we estimate that it will take you
approximately 13 months to pay off the balance shown on
this statement.
Please send billing inquiries and correspondence to:
PO Box XXXX, Anytown, Anystate XXXXX

QUESTIONS?
Call Customer Service
1-XXX-XXX-XXXX
L

Notice of Changes to Your Interest Rates
You have triggered the Penalty APR of 28.99%. This change will impact your account as follows:
Transactions made on or after 4/2/12: As of 5/10/12, the Penalty APR will apply to these transactions.
W
Transactions made before 4/2/12: Current rates will continue to apply to these transactions. However, if you become more
than 30 days late on your account, the Penalty APR will apply to those balances as well.

Transactions
Reference Number

Trans Date

854338203FS8OO0z5

2/25

5884186PS0388w6YM
0544400060zlV72Vl
55541860705RDYD0X
554328608008w90M0
054830709lYMRPT4l
564891561545KOSHD
841517877845AKOJIO
895848561561894KOH
1871556189456SAMKl
2564894185189lKDFID
55542818705RASD0X
178105417841045784
8456152156181SDSA

2/22
2/24
2/24
2/24
2/24
2/25
2/25
2/26
2/26
2/27
3/1
3/2
3/5

Post Date
Description of Transaction or Credit
Payments and Other Credits
2/25
Pymt Thank You
Purchases
2/23
Store #1
2/25
Store #2
2/25
Store #3
2/25
Store #4
2/25
Store #5
2/26
Store #6
2/26
Store #7
2/27
Store #8
2/27
Store #9
2/28
Store #10
3/2
Store #11
3/6
Store #12
3/12
Store #13

Amount
$50.00–
$2.05
$2.11
$4.63
$4.95
$7.35
$4.35
$2.35
$7.68
$4.76
$2.87
$3.76
$2.35
$2.92

(transactions continued on next page)

NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION
Page 1 of 2

Please detach this portion and return with your payment to insure proper credit. Retain upper portion for your records.

Please indicate address change and additional
cardholder requests on the reverse side.

Account Number:

XXXX XXXX XXXX XXXX

New Balance

$119.65

Minimum Payment Due

$10.00

Payment Due Date

4/20/12

AMOUNT ENCLOSED: $

XXX Bank
P.O. Box XXXX
Anytown, Anystate XXXXX

l l l l ll lll llll ll ll llllll ll llll llll ll llll llll lllll

l l l lll lll lll

ll ll

ll ll l l l ll l lll llll ll ll ll lll llll ll

ll l lllll l lll lll ll l ll llll

XXX Bank Credit Card Account Statement
Account Number XXXX XXXX XXXX XXXX
February 21, 2012 to March 22, 2012

Page 2 of 2

Transactions (cont.)
Reference Number

Trans Date

9525156489SFD4545Q
56415615647OJSNDS

2/23
3/22

Post Date
Description of Transaction or Credit
Fees
2/23
late Fee
3/22
Minimum Charge
TOTAL FEES FOR THIS PERIOD
Interest Charged
Interest Charge on Purchases
Interest Charge on Cash Advances
TOTAL INTEREST FOR THIS PERIOD

Amount
$35.00
$2.00
$37.00
$0.00
$0.00
$0.00

2012 Totals Year-to-Date
Total fees charged in 2012

$90.14

Total interest charged in 2012

$18.27

Interest Charge Calculation
Your Annual Percentage Rate (APR) is the annual interest rate on your account.
Annual Percentage Rate (APR)

Balance Subject to
Interest Rate

Purchases

14.99% (v)

$113.80

$0.00

Cash Advances

21.99% (v)

$0.00

$0.00

$0.00

$0.00

Type of Balance

Balance Transfers
(v) = Variable Rate

0.00%

Interest Charge