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MONEYGRAM PAYMENT SYSTEMS, INC.

6701 PARKWAY CIRCLE, MAIL STATION MBC-0023
BROOKLYN CENTER, MN 55430

DEAR MONEY ORDER CUSTOMER:
PER YOUR RECENT REQUEST, BELOW IS THE INFORMATION MONEYGRAM WILL NEED TO FILE A
CLAIM ON YOUR BEHALF. PLEASE KEEP IN MIND, IT IS UP TO THE BANK THAT FIRST DEPOSITED THE
MONEY ORDER TO DETERMINE WHETHER IT IS OBLIGATED TO PAY YOUR CLAIM.
MONEYGRAM HAS A LIMITED AMOUNT OF TIME TO NOTIFY THE BANK THAT ORIGINALLY
DEPOSITED THE MONEY ORDER, AND WE WILL NEED THE FOLLOWING ITEMS IN ORDER TO
SEND A CLAIM ON YOUR BEHALF:
_____1. The enclosed affidavit form must be COMPLETED AND SIGNED IN THE PRESENCE OF A NOTARY
PUBLIC (if outside of the United States of America, THERE MUST BE A CONSULATE STAMP. The Bank
may refuse to research this affidavit if it does not bear a notary or consulate stamp.)
_____2. Please include a copy of the original money order receipt stub if available.
_____3. If law enforcement has been involved, please provide a copy of your police report.
_____4. You must send a $35.00 NON-REFUNDABLE FEE, for each item being processed. Please pay with a money
order made payable to: MONEYGRAM PAYMENT SYSTEMS, INC.
_____5. Affidavits must BE COMPLETED AND RETURNED TO US WITHIN 60 DAYS from the date you
contacted us. If your affidavit and fee are not returned within 60 DAYS, our file on your claim will be closed.
_____6. Please inform us of any address changes by writing to the address at the top of this letter. Please reference the
10 digit money order number on all future correspondence.
If you have any questions regarding the completion of the affidavit, please call our customer service department at 1-800542-3590.
THE FILING OF YOUR AFFIDAVIT WILL NOT TAKE PLACE WITHOUT THE FOLLOWING ITEMS:
ORIGINAL AFFIDAVIT SIGNED AND NOTARIZED
A $35.00 PROCESSING FEE PER ITEM
Upon receipt of your information, we will forward the affidavit to the bank that originally deposited the money order.
The bank will then research your request and respond. This process may take 3-6 months or longer once received by
MoneyGram and we will notify you when we receive a response. Please do not call prior to 120 days after your claim is
filed.
NOTE: THIS AFFIDAVIT DOES NOT GUARANTEE A REFUND WILL BE ISSUED AND MAILED TO YOU.
THE COLLECTABILITY OF YOUR CLAIM WILL BE DETERMINED BY THE BANK OF FIRST DEPOSIT.

 If the Money Order is made payable from you to a business and there is no type of endorsement. signer for drawer” line on front of the Money Order had:  Information removed  Information crossed out  Information changed  Information added If any of these scenarios apply. The name must be the payee or purchaser name on the Money Order.If the back of the Money Order does not indicate any signature (endorsement). and there is an endorsement on the back of the Money Order. Indicate Endorsement Forged on the affidavit. choose Purchaser name Altered.The signature on the back of the Money Order does not belong to the payee or purchaser of the Money Order.The “Pay to the Order” line on the front of the Money Order had:  Information removed  Information crossed out  Information changed  Information added If any of these scenarios apply.Both the “Pay to the Order” line and the “Purchaser. E. signer for drawer” line on the front of the Money Order had:  Information removed  Information crossed out  Information changed  Information added If any of these scenarios apply. Fill out the Money Order Number and Amount at the top of the form. choose Payee Name Altered (Only check this box on the affidavit). (Only check this box on the affidavit).The “Purchaser. choose Payee Name and Purchaser Name was both Altered. The person’s name that was forged must sign the affidavit. Payment Guaranteed”.  If made payable to a business and a stamp appears indicating “Credit to the within named Payee. indicate Not Endorsed by Payee on the affidavit. Do not indicate endorsement forged on affidavit. Send the photo of the items to the business for proof of payment and do not return this affidavit to MoneyGram.  If the Money Order is made payable from you to a business. of any kind. 2. Have them include their name and title. Select ONLY ONE of the reasons listed (according to the guidelines below) and complete all required information on the affidavit form: A. on the back of the Money Order. this indicates that the business received the funds but applied the funds incorrectly. it is not a forged endorsement.  If made payable from you to another person. the purchaser must sign the affidavit. send the affidavit to the business and have a representative of that company sign the affidavit stating they did not cash the Money Order. B. PLEASE NOTE: If the payee or the purchaser signed the back of the Money Order. D. (Only check this box on the affidavit). MoneyGram will complete the Cleared Date. the person whose name appears on the “Pay to the Order” line must sign the affidavit.INSTRUCTIONS FOR COMPLETING THE AFFIDAVIT 1. Please read all choices in items A through E before completing this affidavit. C. The purchaser will receive the refund. . indicating the purchaser and /or payee name on the space provided (Only check this box on the affidavit).

Affidavit for Improperly Negotiated MoneyGram® Money Order Cleared Date (Office use only) Money Order Number (required) Amount (required) $ Please TYPE or PRINT clearly. The original purchaser’s name was altered or changed to _______________________. The purchaser must sign this affidavit. cross out anything or use white out on this page. Payee Name Altered The money order was originally made payable to ______________________________ and was altered or changed to make it payable to the order of _____________________________. The money order does not bear the endorsement of the business and did not benefit in any way by the issuance of this money order. I did not alter the payee’s name nor authorize the alteration. The purchaser must sign this affidavit. but the purchaser will receive the refund. Please do not select more than one box. Notary or Consulate Seal use only ______________________________________________ (SIGNATURE) ______________________________________________ (PRINT OR TYPE NAME) _______________________________________________ (PRINT OR TYPE ADDRESS) _______________________________________________ (PRINT OR TYPE CITY. The purchaser must sign this affidavit. The money order does not bear the endorsement of the payee and the payee has not benefited in any way by the issuance of this money order. The purchaser will receive the refund. I did not alter the purchaser’s name. The purchaser will receive the refund. AFFIDAVIT FOR IMPROPERLY NEGOTIATED MONEYGRAM MONEY ORDER I have not benefited in any way by the issuance or negotiation of said money order. I did not alter either of the purchasers or payees name nor authorize the alteration. The purchaser will receive the refund. Payee Name and Purchaser Name were both Altered The money order was originally made payable to _______________________ and was altered or changed to make it payable to the order of ___________________________.________________ My commission expires: _________________________ Notary Public’s Signature: _________________________ Name (type or printed): _________________________ . please check one of the boxes below) Money order was payable to a person. The person making the claim must sign this form in front of a Notary Public. Completion of this affidavit does NOT GUARANTEE a refund will be issued to you. Money order was payable to a business. The person signing this form will receive the refund. Not Endorsed by Payee (If selected. The party to whom the money order was payable to must sign this affidavit. but the purchaser will receive the refund. STATE AND ZIP CODE) Subscribed and sworn to before me this _________________ Day of_________________________. The person whose name was forged must sign the affidavit. Check ONLY ONE box below that best describes your claim. The business representative to whom the money order was payable to must sign this affidavit. Endorsement Forged The endorsement of ________________________________ on the above item is a forgery. I did not authorize or write the endorsement. Purchaser Name Altered The original purchaser’s name was altered or changed to _________________________.