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.

Merchant accepts only card-not-present (e-commerce or mail/telephone-order) transactions); All processing of cardholder data is entirely outsourced to PCI DSS validated third-party service providers; Merchant does not electronically store, process, or transmit any cardholder data on merchant systems or premises, but relies entirely on a third party(s) to handle all these functions; Merchant has confirmed that all third party(s) handling storage, processing, and/or transmission of cardholder data are PCI DSS compliant; and Merchant retains only paper reports or receipts with cardholder data, and these documents are not received electronically.

Additionally, for e-commerce channels:

All elements of the payment page(s) delivered to the consumer’s browser originate only and directly from a PCI DSS validated third-party service provider(s).

Section 2: Self-Assessment Questionnaire A 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 …

ASV scans are being completed by the PCI SSC Approved Scanning Vendor (ASV Name) Part 3b. Merchant Attestation Signature of Merchant Executive Officer  Date:

Merchant Executive Officer Name: Title:

Part 3c. QSA Acknowledgement (if applicable) If a QSA was involved or assisted with this assessment, describe the role performed:

Signature of Duly Authorized Officer of QSA Company  Date:

Duly Authorized Officer Name: QSA Company:

Part 3d. ISA Acknowledgement (if applicable) If a ISA was involved or assisted with this assessment, describe the role performed:

Signature of ISA  Date:

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

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 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.