Model Form for Short Form Disclosures for Prepaid Accounts with Multiple Service Plans

Type of fee Pay-as-you-go plan Monthly 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:
Type of fee Pay-as-you-go plan Monthly plan Annual plan
[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.