Transaction Receipts

Electronic Fund Transfer Act (Regulation E) 12 CFR 1005

A-31 Form 1.11.12

Transaction Receipts

OMB: 3170-0014

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A-31 – Model Form for Receipts for Remittance Transfers Exchanged into Local Currency (§ 1005.31(b)(2))

ABC Company

1000 XYZ Avenue
Anytown, Anystate 12345

Today’s Date: March 3, 2013

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: March 4, 2013

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

Other Taxes: -10.00 MXN

Total to Recipient: 1,187.00 MXN

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




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

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