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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.

PCI DSS Requirement* Description of Requirement Compliant to PCI DSS Requirements (Select One) Remediation Date and Actions (If “NO” selected for any Requirement) YES NO Do not use vendor-supplied defaults for system passwords and other security parameters 8 Identify and authenticate access to system components 9 Restrict physical access to cardholder data Maintain a policy that addresses information security for all personnel * PCI DSS Requirements indicated here refer to the questions in Section 2 of the SAQ.