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A–30—Model form for pre-payment disclosures for remittance transfers exchanged into
local currency (§ 205.31(b)(1))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Today’s Date:

3/03/2011

NOT A RECEIPT
Transfer Amount:
Transfer Fees and Taxes:
Total:

Exchange Rate:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

1,227.00 MXN
-40.00 MXN
1,187.00 MXN

A–31—Model form for receipts for remittance transfers exchanged into local currency
(§ 205.31(b)(2))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Today’s Date:

3/03/2011

RECEIPT
SENDER:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
222-555-1212
RECIPIENT:
Carlos Gomez
123 Calle XXX
Mexico City
Mexico
PICK-UP LOCATION:
ABC Company
65 Avenida YYY
Mexico City
Mexico

Confirmation Code:

ABC 123 DEF 456

Date Available:

3/04/2011

Transfer Amount:
Transfer Fees and Taxes:
Total:

Exchange Rate:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

1,227.00 MXN
-40.00 MXN
1,187.00 MXN

Problems or questions? Contact us
within 180 days at 800-123-4567 or
www.abccompany.com. You can contact
us for a written explanation of your
rights.

You can cancel for a full refund
within 1 business day of payment,
unless the funds have been picked
up/deposited.

For questions or complaints about ABC
Company, contact:

State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau

800-555-9999
www.consumerfinance.gov

A–32—Model form for combined disclosures for remittance transfers exchanged into local
currency (§ 205.31(b)(3))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Today’s Date:

3/03/2011

SENDER:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
222-555-1212
RECIPIENT:
Carlos Gomez
123 Calle XXX
Mexico City
Mexico
PICK-UP LOCATION:
ABC Company
65 Avenida YYY
Mexico City
Mexico

Confirmation Code:

ABC 123 DEF 456

Date Available:

3/04/2011

Transfer Amount:
Transfer Fees and Taxes:
Total:

Exchange Rate:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

1,227.00 MXN
-40.00 MXN
1,187.00 MXN

Problems or questions? Contact us
within 180 days at 800-123-4567 or
www.abccompany.com. You can contact
us for a written explanation of your
rights.

You can cancel for a full refund
within 1 business day of payment,
unless the funds have been picked
up/deposited.

For questions or complaints about ABC
Company, contact:
State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau
800-555-9999
www.consumerfinance.gov

A–33—Model form for pre-payment disclosures for dollar-to-dollar remittance
transfers (§ 205.31(b)(1))

ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345
Today’s Date:

3/03/2011

NOT A RECEIPT

Transfer Amount:
Transfer Fees and Taxes:
Total:

$100.00
$10.00
$110.00

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

$100.00
-$5.00
$95.00

A–34—Model form for receipts for dollar-to-dollar remittance transfers (§ 205.31(b)(2))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345
Today’s Date:

3/03/2011

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:

3/04/2011

Transfer Amount:
Transfer Fees and Taxes:
Total:

$100.00
$10.00
$110.00

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

$100.00
-$5.00
$95.00

Problems or questions? Contact us within 180 days at 800-123-4567 or
www.abccompany.com. You can contact us for a written explanation of your
rights.
You can cancel for a full refund within 1 business day of payment, unless the
funds have been picked up/deposited.

For questions or complaints about ABC Company, contact:
State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau
800-555-9999
www.consumerfinance.gov

A–35—Model form for combined disclosures for dollar-to-dollar remittance transfers
(§ 205.31(b)(3))

ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345
Today’s Date:

3/03/2011

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:

3/04/2011

Transfer Amount:
Transfer Fees and Taxes:
Total:

$100.00
$10.00
$110.00

Transfer Amount:
Other Fees and Taxes:
Total to Recipient:

$100.00
-$5.00
$95.00

Problems or questions? Contact us within 180 days at 800-123-4567 or
www.abccompany.com. You can contact us for a written explanation of your
rights.
You can cancel for a full refund within 1 business day of payment, unless the
funds have been picked up/deposited.

For questions or complaints about ABC Company, contact:
State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau
800-555-9999
www.consumerfinance.gov

A–36—Model form for error resolution and cancellation disclosures (long) (§ 205.31(b)(4))

What To Do If You Think There Has Been An Error or Problem:
If you think there has been an error or problem with your remittance transfer:
•

Call us at [insert telephone number][; or]

•

Write us at [insert address][; or]

•

[E-mail us at [insert electronic mail address].

You must contact us within 180 days of the date we promised to you that funds would be made
available to the recipient. When you do, please tell us:
(1) Your name and address [or telephone number];
(2) The error or problem with the transfer, and why you believe it is an error or problem;
(3) The name of the person receiving the funds, and if you know it, his or her telephone
number or address; [and]
(4) The dollar amount of the transfer; [and
(5) The confirmation code or number of the transaction.]
We will determine whether an error occurred within 90 days after you contact us and we will
correct any error promptly. We will tell you the results within three business days after
completing our investigation. If we decide that there was no error, we will send you a written
explanation. You may ask for copies of any documents we used in our investigation.
What To Do If You Want To Cancel A Remittance Transfer:
You have the right to cancel a remittance transfer and obtain a refund of all funds paid to us,
including any fees. In order to cancel, you must contact us at the [phone number or e-mail
address] above within one business day of payment for the transfer.
When you contact us, you must provide us with information to help us identify the transfer you
wish to cancel, including the amount and location where the funds were sent. We will refund
your money within three business days of your request to cancel a transfer as long as the funds
have not already been picked up or deposited into a recipient’s account.

A–37—Model form for error resolution and cancellation disclosures (short)
(§ 205.31(b)(2)(vi))
Problems or questions? Contact us within 180 days at 800-123-4567 or www.abccompany.com.
You can contact us for a written explanation of your rights.
You can cancel for a full refund within 1 business day of payment, unless the funds have been
picked up/deposited.
For questions or complaints about ABC Company, contact:

A–38—Model form for pre-payment disclosures—Spanish (§ 205.31(b)(1))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Fecha:

3/03/2011

NO ES UN RECIBO
Cantidad de Envío:
Tarifas e Impuestos:
Total:

Tasa de Cambio:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Cantidad de Envío:
1,227.00 MXN
Otras Tarifas e Impuestos: -40.00 MXN
Total a Destinatario:
1,187.00 MXN

A–39—Model form for receipts—Spanish (§ 205.31(b)(2))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Fecha:

3/03/2011

RECIBO
REMITENTE:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
222-555-1212
DESTINATARIO:
Carlos Gomez
123 Calle XXX
Mexico City
Mexico
RETIRAR EN:
ABC Company
65 Avenida YYY
Mexico City
Mexico

Código de Confirmación:ABC 123 DEF 456

Fecha Disponible:

3/04/2011

Cantidad de Envío:
Tarifas e Impuestos:
Total:

Tasa de Cambio:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Cantidad de Envío:
1,227.00 MXN
Otras Tarifas e Impuestos: -40.00 MXN
Total a Destinatario:
1,187.00 MXN

¿Problemas o preguntas? Contáctenos
dentro de 180 días a 800-123-4567 o
www.abccompany.com. Puede
contactarnos para una explicación
escrita de sus derechos.

Puede cancelar para un reembolso
total dentro de un día hábil del
pago, a no ser que los fundos han
sido retirados o depositados.

Para preguntas o presentar una queja
en ABC Company, contacte a:

State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau
800-555-9999
www.consumerfinance.gov

A–40—Model form for combined disclosures—Spanish (§ 205.31(b)(3))
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345

Fecha:

3/03/2011

REMITENTE:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
222-555-1212
DESTINATARIO:
Carlos Gomez
123 Calle XXX
Mexico City
Mexico
RETIRAR EN:
ABC Company
65 Avenida YYY
Mexico City
Mexico

Código de Confirmación:ABC 123 DEF 456

Fecha Disponible:

3/04/2011

Cantidad de Envío:
Tarifas e Impuestos:
Total:

Tasa de Cambio:

$100.00
$10.00
$110.00

US$1.00 = 12.27 MXN

Cantidad de Envío:
1,227.00 MXN
Otras Tarifas e Impuestos: -40.00 MXN
Total a Destinatario:
1,187.00 MXN

¿Problemas o preguntas? Contáctenos
dentro de 180 días a 800-123-4567 o
www.abccompany.com. Puede
contactarnos para una explicación
escrita de sus derechos.

Puede cancelar para un reembolso
total dentro de un día hábil del
pago, a no ser que los fundos han
sido retirados o depositados.

Para preguntas o presentar una queja
en ABC Company, contacte a:

State Regulatory Agency
800-111-2222
www.stateregulatoryagency.com
Consumer Financial Protection Bureau
800-555-9999
www.consumerfinance.gov

A–41—Model form for error resolution and cancellation disclosures (long) —Spanish
(§ 205.31(b)(4))

Lo Que Usted Debe Hacer Si Cree Que Haya Un Error O Problema:
Si cree que haya un error o problema con su envío de dinero:
•

Llámenos a [inserte número de teléfono][; o]

•

Escribanos a [inserte dirección][; o]

•

[Mándenos un e-mail a [inserte dirección de correo electrónico].

Debe contactarnos dentro de 180 días de la fecha que se le prometió que los fundos estarían
disponibles al destinatario. Cuando se comunique con nosotros, por favor provee la siguiente
información:
(1) Su nombre y dirección [o número de teléfono];
(2) El error o problema con su envío de dinero, y porque cree que haya un error o problema;
(3) El nombre del destinatario, y si lo sabe, su número de teléfono o dirección; [y]
(4) El monto a enviar en dólares; [y
(5) El código de confirmación o el número de la transacción.]
Nosotros determinaremos si haya un error dentro de 90 días después de usted nos contacta y
corrigiéremos el error rápidamente. Le diremos los resultados dentro de tres días hábiles después
de terminar nuestra investigación. Si decidimos que no había un error, le mandaremos a usted
una explicación escrita. Puede pedir copias de los documentos que usamos en nuestra
investigación.
Lo Que Usted Debe Hacer Si Quiere Cancelar Un Envío De Dinero:
Tiene el derecho de cancelar un envío de dinero y obtener un reembolso de todo el dinero,
incluyendo tarifas o gastos que usted nos pagó. Para cancelar, debe contactarnos al [número de
teléfono o dirección de correo electrónico] que se encuentra arriba dentro de un día hábil del
pago para el envío de dinero.
Cuando nos contacte, debe proveernos con información que nos ayudará a identificar el envío de
dinero que quiere cancelar, inclusivo la cantidad del envió y el lugar donde fue enviado. Le
reembolsamos su dinero dentro de tres días hábiles de su petición de cancelar a no ser que los
fundos han sido retirados o depositados en la cuenta del destinatario.