Regulation E Reporting, Recodkeeping and Disclosure requirements

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

A-32 – Model Form for Combined Disclosures for Remittance Transfers Exchanged into Local Currency (§ 10
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Today’s Date: March 3, 2013
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

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

A-34 – Model Form for Receipts for Dollar-to-Dollar Remittance Transfers (§ 1005.31(b)(2))
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Today’s Date: March 3, 2013

RECEIPT
SENDER: RECIPIENT:
Pat Jones Carlos Gomez
100 Anywhere Street 106 Calle XXX
Anytown, Anywhere 54321 Mexico City
301-555-1212 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
Transfer Amount: $100.00
Other Fees: -$4.00
Other Taxes: -$1.00
Total to Recipient: $95.00
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

A-35 – Model Form for Combined Disclosures for Dollar-to-Dollar Remittance Transfers (§
1005.31(b)(3))
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Today’s Date: March 3, 2013
SENDER: RECIPIENT:
Pat Jones Carlos Gomez
100 Anywhere Street 106 Calle XXX
Anytown, Anywhere 54321 Mexico City
301-555-1212 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
Transfer Amount: $100.00
Other Fees: -$4.00
Other Taxes: -$1.00
Total to Recipient: $95.00
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

A-36 – Model Form for Error Resolution and Cancellation Disclosures (Long) (§
1005.31(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 30 minutes 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) (§§
1005.31(b)(2)(iv) and (b)(2)(vi))
You have a right to dispute errors in your transaction. If you think there is an error, contact us within
180 days at [insert telephone number] or [insert website]. 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 [insert name of remittance transfer provider], contact:

A-38 – Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency – Span
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Fecha: 3 de marzo de 2013

ESTE NO ES UN RECIBO
Cantidad de Envío: $100.00
Cargos por Envío: +$7.00
Envío: +$3.00 Impuestos de
Total: $110.00
Tasa de Cambio: US$1.00 = 12.27 MXN
Cantidad de Envío: 1,227.00 MXN
Otros Cargos por Envío: -30.00 MXN
Otros Impuestos de
: -10.00 MXN Envío
Total al Destinatario: 1,187.00 MXN

A-39 – Model Form for Receipts for Remittance Transfers Exchanged into Local Currency – Spanish (§ 1005.
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Fecha: 3 de marzo de 2013

RECIBO
REMITENTE:
Pat Jones
100 Anywhere Street

Anytown, Anywhere 54321
222-555-1212
DESTINATARIO:
Carlos Gomez
123 Calle XXX
Ciudad de Mexico, D.F.
Mexico
PUNTO DE PAGO:
ABC Company
65 Avenida YYY
Ciudad de Mexico, D.F.
Mexico
Código de Confirmación: ABC 123 DEF 456
Fecha Disponible: 4 de marzo de 2013
Cantidad de Envío: $100.00
Cargos por Envío: +$7.00
Envío: +$3.00 Impuestos de
Total: $110.00
Tasa de Cambio: US$1.00 = 12.27 MXN
Cantidad de Envío: 1,227.00 MXN
Otros Cargos por Envío: -30.00 MXN
Otros Impuestos de
: -10.00 MXN Envío
Total al Destinatario: 1,187.00 MXN
Usted tiene el derecho de discutir errores en su transaccion. Si cree que hay un error,
contáctenos dentro de 180 días al 800-123-4567 o www.abccompany.com. También puede contactarnos
para obtener una explicación escrita de sus derechos.
Puede cancelar el envío y recibir un reembolso total dentro de 30 minutos de haber realizado el
pago, a no ser que los fondos hayan sido recogidos o depositados.
Para preguntas o presentar una queja sobre ABC Company, contacte a:

State Regulatory Agency
800-111-2222
www.stateregulatoryagency.gov
Consumer Financial Protection Bureau
855-411-2372
855-729-2372 (TTY/TDD)
www.consumerfinance.gov

A-40 – Model Form for Combined Disclosures for Remittance Transfers Exchanged into Local Currency – Sp
ABC Company
1000 XYZ Avenue Anytown, Anystate 12345
Fecha: 3 de marzo de 2013
REMITENTE:
Pat Jones
100 Anywhere Street
Anytown, Anywhere 54321
222-555-1212
DESTINATARIO:
Carlos Gomez
123 Calle XXX
Ciudad de Mexico, D.F.
Mexico
PUNTO DE PAGO:
ABC Company
65 Avenida YYY
Ciudad de Mexico, D.F.
Mexico
Código de Confirmación: ABC 123 DEF 456
Fecha Disponible: 4 de marzo de 2013
Cantidad de Envío: $100.00
Cargos por Envío: +$7.00
Envío: +$3.00 Impuestos de
Total: $110.00
Tipo de Cambio: US$1.00 = 12.27 MXN
Cantidad de Envío: 1,227.00 MXN
Otros Cargos por Envío: -30.00 MXN
Otros Impuestos de
: -10.00 MXN Envío
Total al Destinatario: 1,187.00 MXN
Usted tiene el derecho de discutir errores en su transaccion. Si cree que hay un error,
contáctenos dentro de 180 días al 800-123-4567 o www.abccompany.com. También puede contactarnos
para obtener una explicación escrita de sus derechos.
Puede cancelar el envío y recibir un reembolso total dentro de 30 minutos de haber realizado el
pago, a no ser que los fondos hayan sido recogidos o depositados.
Para preguntas o presentar una queja sobre ABC Company, contacte a:

State Regulatory Agency
800-111-2222
www.stateregulatoryagency.gov
Consumer Financial Protection Bureau
855-411-2372
855-729-2372 (TTY/TDD)
www.consumerfinance.gov

A-41 – Model Form for Error Resolution and Cancellation Disclosures (Long) – Spanish (§
1005.31(b)(4))
Lo que usted debe hacer si cree que hay un error o problema:
Si cree que hay un error o problema con su envío de dinero:
• Llámenos a [inserte número de teléfono][; o]
• Escríbanos a [inserte dirección][; o]
• [Envíenos un correo electrónico a [inserte dirección de correo electrónico].
Debe contactarnos dentro de 180 días a partir de la fecha en que se le prometió que los fondos
estarían disponibles al destinatario. Cuando se comunique con nosotros, por favor provea la siguiente
información:
(1) Su nombre y dirección [o número de teléfono];
(2) El error o problema con su envío de dinero, y por qué cree que hay un error o problema;
(3) El nombre del destinatario, y si lo sabe, su número de teléfono o dirección; [y]
(4) El monto del envío en dólares; [y
(5) El código de confirmación o el número de la transacción.]
Nosotros determinaremos si ocurrió un error dentro de 90 días después de que usted nos contacte y lo
corregiremos rápidamente. Le diremos los resultados dentro de tres días hábiles después de terminar
nuestra investigación. Si decidimos que no hubo un error, le enviaremos a usted una explicación
escrita. Usted 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 30 minutos de haber
realizado el pago para el envío de dinero.
Cuando nos contacte, debe proveernos información que nos ayudará a identificar el envío de dinero
que quiere cancelar, incluyendo la cantidad del envío y el lugar adonde fue enviado. Le
reembolsaremos su dinero dentro de tres días hábiles de su petición de cancelar, a no ser que los
fondos hayan sido recogidos o depositados en la cuenta del destinatario.