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  5. A-30(a)
6-5357

A-30(a)—Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency (section 1005.31(b)(1))

Model Form for Pre-Payment Disclosures for Remittance Transfers Exchanged into Local Currency
ABC Company
1000 XYZ Avenue
Anytown, Anystate 12345
Today’s Date: March 3, 2014
NOT A RECEIPT
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
Total to Recipient: 1,197.00 MXN
Recipient may receive less due to fees charged by the recipient’s bank and foreign taxes.
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