Document Comparison

Section 1: Assessment Information Instructions for Submission This document must be completed as a declaration of the results of the merchant’s self-assessment with the Payment Card Industry Data Security Standard Requirements and Security Assessment Procedures (PCI DSS). Complete all sections: The merchant is responsible for ensuring that each section is completed by the relevant parties, as applicable. Contact acquirer (merchant bank) or the payment brands to determine reporting and submission procedures.

ISA Name(s) (if applicable): Title:

Part 1b. Qualified Security Assessor Company Information (if applicable) Company Name:

Lead QSA Contact Name: Title:

What types of payment channels does your business serve?

Mail order/telephone order (MOTO) E-Commerce Card-present (face-to-face) Which payment channels are covered by this SAQ? Mail order/telephone order (MOTO) E-Commerce Card-present (face-to-face)

Note: If your organization has a payment channel or process that is not covered by this SAQ, consult your acquirer or payment brand about validation for the other channels.

Type of facility Number of facilities of this type Location(s) of facility (city, country) Example: Retail outlets 3 Boston, MA, USA Part 2d. Payment Application Does the organization use one or more Payment Applications? Yes No Provide the following information regarding the Payment Applications your organization uses:

Payment Application Version Number Application Is application PA-DSS Listed? PA-DSS Listing Expiry date (if applicable) Part 2e. Description of Environment Provide a high-level description of the environment covered by this assessment.

For example:

• Connections into and out of the cardholder data environment (CDE).

• Critical system components within the CDE, such as POS devices, databases, web servers, etc., and any other necessary payment components, as applicable.

Does your business use network segmentation to affect the scope of your PCI DSS environment? (Refer to “Network Segmentation” section of PCI DSS for guidance on network segmentation)

Note: Requirement 12.8 applies to all entities in this list.

Section 2: Self-Assessment Questionnaire C This Attestation of Compliance reflects the results of a self-assessment, which is documented in an accompanying SAQ.

The assessment documented in this attestation and in the SAQ was completed on:

Have compensating controls been used to meet any requirement in the SAQ? Yes No Were any requirements in the SAQ identified as being not applicable (N/A)? Yes No Were any requirements in the SAQ unable to be met due to a legal constraint? Yes No

Section 3: Validation and Attestation Details Part 3. PCI DSS Validation Based on the results noted in the SAQ C dated (completion date), the signatories identified in Parts 3b-3d, as applicable, assert(s) the following compliance status for the entity identified in Part 2 of this document as of (date): (check one):

Compliant but with Legal exception: One or more requirements are marked “No” due to …

Check with your acquirer or the payment brand(s) before completing Part 4.