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Please check the appropriate boxes that apply to the identified merchant. Specifically, mark off if the merchant was
identified in the VCMP, VFMP, or both. Fill in the timeline month applicable at the time of plan submission, e.g. 2-
Workout or 5-Enforcement. Also, mark if the identification pertains to the Standard, High-Risk or Excessive program
timelines. Provide the date the original plan, and any subsequent updates, were submitted.
1. Acquirer Name:
2. Merchant Descriptor:
3. Principal Name(s):
15. Description of Merchant’s Business: (Provide a clear understanding of who the merchant is, what they do, and
how they operate. Include merchant’s business type, products and services offered, the manner in which they
conduct their business, marketing and sales activities, affiliates, third parties utilized to sell products/services, and a
statement on the merchant’s policy on credits and returns.)
5. Business Model: ☐ Retail Sales - Goods ☐ Free Trial Period followed by Membership Fees
(Check all that apply)
☐ Retail Sales - Services ☐ Recurring Charges ☐ Gift Card Sales
☐ Rule-based Fraud System (e.g., CyberSource Decision Manager) Date Implemented (MM/YY):
2. Explanation of the Mitigation Tools in Place: (Elaborate on the tools and processes indicated and include any
other preventive tools not represented in Section E. If applicable, include parameters and thresholds for the tools
utilized—indicate effectiveness and provide supporting evidence.)
1. Corrective Actions: (Provide the specific actions undertaken in order to reduce chargebacks and/or mitigate
fraud activity.)
1. If the Merchant qualifies for NCAs, are you asking for a suspension? ☐ No ☐ Yes
Name:
Title:
Email:
Telephone:
Date:
Signature: