Automated Teller Machine Registration

completion (or by means of a sign placed on the Terminal in a manner clearly visible to the cardholder if the Terminal does not have a screen), the Terminal Owner must provide: 1. A clear explanation that a surcharge is being imposed in connection with the cardholder's transaction by the Terminal Owner and not the issuer of the card, and that the surcharge is an additional fee that will be deducted from the cardholder's account, in addition to any fee that may be imposed by the issuer of the card; 2. The amount of the surcharge that will be imposed in connection with the transaction; and 3. The method by which the cardholder may cancel the transaction to avoid imposition of the surcharge. Each Terminal Owner is required to submit the following information to the Commissioner for approval prior to the activation of each Terminal: 1. The location of the Terminal; 2. Samples of all disclosures to be used in compliance with Section 10302; 3. A script or a legible photo of the on-screen disclosures to be used ( or copy of the sign to be used if the Terminal does not have a screen); and 4. Detailed description of where and how such disclosures shall be made to the cardholder. Failure to obtain. the Commissioner's approval of the disclosures prior to the activation of a Terminal may lead to the imposition of sanctions and/or fines. An Automated Teller Machine Registration is found below. Requirements in this Bulletin may be amended from time to time. Michael Pieciak, Commissioner Department of Financial Regulation AUTOMATED TELLER MACHINE REGISTRATION Vermont Department of Financial Regulation 89 Main Street • Montpelier VT • 05620-3101 802-828-3307 • dfr.bnkconsumer@vermont.gov After completing this form, please email to the Department Banking Division at dfr.bnkconsumer@vermont.gov. Date 1. Owner of Terminal Business Name Address Street Address (include PO Box and Unit/Suite No.) City State Zip Contact Telephone No. Extension Email 2. Customer Service Contact Name Telephone No. 3. Servicer Information Servicer Name Address Telephone No. 4. Location of Terminal Company/Business name where ATM will be located Address Street Address City State Zip 5. Date of Terminal Activation 6. Date of Terminal Deactivation