Transaction Receipts

Electronic Fund Transfer Act (Regulation E) 12 CFR 1005

A-33 Form 1.11.12

Transaction Receipts

OMB: 3170-0014

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A-33 – Model form for Pre-Payment Disclosures for Dollar-to-Dollar Remittance Transfers (§ 1005.31(b)(1))



ABC Company

1000 XYZ Avenue
Anytown, Anystate 12345

Today’s Date: March 3, 2013

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

Other Taxes: -$1.00

Total to Recipient: $95.00




File Typeapplication/msword
AuthorV. Wong
Last Modified ByMandie Aubrey
File Modified2012-01-11
File Created2012-01-11

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