Regulation E Reporting, Recodkeeping and Disclosure requirements

Model and sample pre-acquisition disclosure
forms for prepaid accounts
On October 5, 2016, the Consumer
Financial Protection Bureau (the Bureau)
released a final rule governing Prepaid
Accounts under the Electronic Fund
Transfer Act (Regulation E) and the Truth
In Lending Act (Regulation Z).
The final rule establishes pre-acquisition disclosure
requirements specific to prepaid accounts. Under
the final rule, financial institutions must generally
provide both a “short form” disclosure and a “long
form” disclosure before a consumer acquires a
prepaid account.

The final rule itself as well as a number of related
materials are available at www.consumerfinance.
gov/prepaid-rule. In addition, for the convenience
of the prepaid industry and to help reduce
development costs, the Bureau is also providing
native design files for print and source code for
web-based disclosures for all of the model and
sample forms included in the final rule. See
www.consumerfinance.gov/prepaid-disclosure-files.

The final rule includes several model short
form disclosures that offer a safe harbor to the
financial institutions that use them, provided
that the model forms are used accurately and
appropriately. The final rule also includes one
sample long form disclosure as an example of how
financial institutions might choose to structure
this disclosure. The final rule’s model and sample
disclosure forms appear below.

Consumer Financial
Protection Bureau

1

Model form A-10(a) for Short Form Disclosures for Government Benefit Accounts
(§1005.15(c) and §1005.18(b)(2), (3), (6), and (7))

You have several options to receive your payments: direct deposit to your
bank account; direct deposit to your own prepaid account; or this benefits card.
Tell the benefits office which option you choose.
Monthly fee

$0

Per purchase

$0

ATM withdrawal

Cash reload

$0 in-network
N/A
$1.95*out-of-network

ATM balance inquiry (in-network or out-of-network)

$0 or $1.95*

Customer service (automated or live agent)

$0 or $1.95 per call

Inactivity

$0

We charge 4 other types of fees. Here are some of them:
[Additional fee type]

$0.50 or $1.00

[Additional fee type]

$3.00

* This fee can be lower depending on how and where this card is used.
[See [location] for free ways to access your funds and balance information.]
No overdraft/credit feature.
Your funds are eligible for FDIC insurance.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services in the cardholder agreement.

Consumer Financial
Protection Bureau

2

Model form A-10(b) for Short Form Disclosures for Payroll Card Accounts
(§1005.18(b)(2), (3), (6), and (7))

You do not have to accept this payroll card.
Ask your employer about other ways to receive your wages.
Monthly fee

$0

Per purchase

$0

ATM withdrawal

Cash reload

$0 in-network
N/A
$1.95*out-of-network

ATM balance inquiry (in-network or out-of-network)

$0 or $1.95*

Customer service (automated or live agent)

$0 or $1.95 per call

Inactivity

$0

We charge 4 other types of fees. Here are some of them:
[Additional fee type]

$1.00*

[Additional fee type]

$3.00

* This fee can be lower depending on how and where this card is used.
[See [location] for free ways to access your funds and balance information.]
No overdraft/credit feature.
Your funds are eligible for FDIC insurance.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services in the cardholder agreement.

Consumer Financial
Protection Bureau

3

Model form A-10(c) for Short Form Disclosures for Prepaid Accounts, Example 1
(§1005.18(b)(2), (3), (6), and (7))

Monthly fee

$5.99

†

Per purchase

$0

ATM withdrawal

$0 in-network
$1.99 out-of-network

Cash reload

$3.99*

ATM balance inquiry (in-network or out-of-network)

$0 or $0.50

Customer service (automated or live agent)

$0 or $0.50* per call

Inactivity (after 12 months with no transactions)

$1.00 per month

We charge 4 other types of fees. Here are some of them:
[Additional fee type]

$0.50 or $1.00

[Additional fee type]

$3.00

†

No monthly fee with direct deposit or 30 transactions per month.
* This fee can be lower depending on how and where this card is used.
You may be offered overdraft/credit after 30 days. Fees would apply.
Register your card for FDIC insurance eligibility and other protections.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services inside the package,
or call 800-234-5678 or visit xyz.com/prepaid.

Consumer Financial
Protection Bureau

4

Model form A-10(d) for Short Form Disclosures for Prepaid Accounts, Example 2
(§1005.18(b)(2), (3), (6), and (7))

Monthly fee

Per purchase

$5.99* $0

ATM withdrawal

$0 in-network
$1.99 out-of-network

Cash reload

$3.99*

ATM balance inquiry (in-network or out-of-network)

$0 or $0.50

Customer service (automated or live agent)

$0 or $0.50* per call

Inactivity (after 12 months with no transactions)

$1.00 per month

We charge 4 other types of fees. Here are some of them:
[Additional fee type]

$1.00*

[Additional fee type]

$3.00

* This fee can be lower depending on how and where this card is used.
No overdraft/credit feature.
Not FDIC insured. Register your card for other protections.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services inside the package,
or call 800-234-5678 or visit xyz.com/prepaid.

Consumer Financial
Protection Bureau

5

Model form A-10(e) for Short Form Disclosures for Prepaid Accounts With Multiple Service Plans
(§1005.18(b)(2), (3), (6), and (7))

Pay-asMonthly
you-go plan plan

Annual
plan

Plan fee

$0

$5.99† per mo. $39.99 per yr.

Per purchase

$0.25

$0

$0

ATM withdrawal (in-net.)

$0

$0

$0

ATM withdrawal (out-net.)

$2.50

$1.99

$1.99

Cash reload

$4.99*

$4.99*

$4.99*

ATM balance inquiry (in-net.)

$0.50

$0.50

$0.50

ATM balance inquiry (out-net.)

$1.00

$1.00

$1.00

Live customer service (per call)

$1.50

$0.50

$0.50

Inactivity (after 12 mo. w/ no trans.) $2.50 per mo. $2.50 per mo.

$2.50 per mo.

We charge 4 other types of fees. Here are some of them:
[Additional fee type]

$1.00*

$1.00*

$1.00*

[Additional fee type]

$3.00

$3.00

$3.00

†

$1.00 monthly fee with direct deposit.
* This fee can be lower depending on how and where this card is used.
No overdraft/credit feature.
Not FDIC insured. Register your card for other protections.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services inside the package,
or call 800-234-5678 or visit xyz.com/prepaid.

Consumer Financial
Protection Bureau

6

Sample Form A-10(f) for Long Form Disclosures for Prepaid Accounts (§1005.18(b)(4), (6), and (7))
List of all fees for XYZ Prepaid Card
All fees

Amount

Details

Get started
Card purchase

$3.95

Monthly usage
Monthly fee

$5.99

Monthly fee is waived in any month in which you receive a direct deposit or conduct at
least 30 transactions.

Add money
Direct deposit

$0.50

Cash reload

$3.99

Fees of up to $3.99 may apply when reloading your card at XYZ reload agents.
Locations may be found at xyzbank.com/prepaid/reloads.

Bill payment (regular delivery)

$0.50

Bill pay available when you log in to your account at xyzbank.com/prepaid or using the XYZ Bank
mobile app. Regular bill pay transactions will be completed within 3 business days for electronic
payments and within approximately 7 days if we have to mail a paper check to pay your bill.

Bill payment (expedited delivery)

$1.00

Bill pay available when you log in to your account at xyzbank.com/prepaid or using the XYZ Bank
mobile app. Expedited bill pay transactions will be completed within 1 business day. Electronic
payments only.

ATM withdrawal (in-network)

$0

“In-network” refers to the XYZ Bank ATM Network. Locations can be found at xyzbank.com/ATMs.

ATM withdrawal
(out-of-network)

$1.99

This is our fee. We will not charge you this fee for your first 3 out-of-network ATM withdrawals
each month. “Out-of-network” refers to all the ATMs outside of the XYZ Bank ATM Network. You
may also be charged a fee by the ATM operator, even if you do not complete a transaction.

Customer service (automated)

$0

No fee for calling our automated customer service line, including for balance inquiries.

Customer service (live agent)

$0.50

Per call. First 3 calls per month are free.

ATM balance inquiry (in-network)

$0

“In-network” refers to the XYZ Bank ATM Network. Locations can be found at xyzbank.com/ATMs.

ATM balance inquiry
(out-of-network)

$0.50

This is our fee. “Out-of-network” refers to all the ATMs outside of the XYZ Bank ATM Network.
You may also be charged a fee by the ATM operator.

International transaction

3%

Of the U.S. dollar amount of each transaction.

International ATM withdrawal

$3.00

This is our fee. You may also be charged a fee by the ATM operator, even if you do not
complete a transaction.

International ATM balance inquiry

$2.00

This is our fee. You may also be charged a fee by the ATM operator.

$1.00

You will be charged $1.00 each month after you have not completed a transaction using your
card for 12 months.

Spend money

Get cash

Information

Using your card outside the U.S.

Other
Inactivity

Register your card for FDIC insurance eligibility and other protections. Your funds will be held at or transferred to XYZ Bank, an FDIC-insured institution.
Once there, your funds are insured up to $250,000 by the FDIC in the event XYZ Bank fails, if specific deposit insurance requirements are met and your
card is registered. See fdic.gov/deposit/deposits/prepaid.html for details.
No overdraft/credit feature.
Contact XYZ Bank by calling 1-800-555-5555, by mail at 555 Street Name, Anytown, NY, or visit xyzbank.com/prepaid.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
If you have a complaint about a prepaid account, call the Consumer Financial Protection Bureau at 1-855-411-2372 or visit cfpb.gov/complaint.