Affidavit of Service Form

CONSUMER SERVICE AFFIDAVIT INSTRUCTIONS FOR USE Use this form to request the status of a money order when you have the serial number but not the money order receipt. The form must be completed by the purchaser and signed by a Notary Public* Send completed form and a 15. 00 check or money order to Integrated Payment Systems PO Box 7030 Englewood CO 80155-7030 If the money order has not been cashed the company will receive a refund. If the money order has been cashed you will receive a photocopy of the front and back of the item* It may take up to 30 days to receive the refund or photocopy. STATE ss COUNTY I of Address Phone being duly sworn do depose and say that I am the purchaser of the Money Order issued by Western Union* This Money Order was purchased at on the approximate date of for Dollars and made payable to that I never received payment therefore and that I never received directly or indirectly any benefit therefrom* To induce Western Union to refund to me the face amount of the above Money Order and in consideration of that payment I authorize Western Union to stop payment on this Money Order and agree to reimburse Western Union for this refund and to hold Western Union harmless against any and all expense and/or liability to which it may be subject by reason of this refund to me by reason of my alleged loss of Money Order or by reason of the negotiation of the Money Order. Signed Date Subscribed and sworn to before me this day date month year My commission expires. month day year NOTARY PUBLIC. The form must be completed by the purchaser and signed by a Notary Public* Send completed form and a 15. 00 check or money order to Integrated Payment Systems PO Box 7030 Englewood CO 80155-7030 If the money order has not been cashed the company will receive a refund. 00 check or money order to Integrated Payment Systems PO Box 7030 Englewood CO 80155-7030 If the money order has not been cashed the company will receive a refund. If the money order has been cashed you will receive a photocopy of the front and back of the item* It may take up to 30 days to receive the refund or photocopy. If the money order has been cashed you will receive a photocopy of the front and back of the item* It may take up to 30 days to receive the refund or photocopy. STATE ss COUNTY I of Address Phone being duly sworn do depose and say that I am the purchaser of the Money Order issued by Western Union* This Money Order was purchased at on the approximate date of for Dollars and made payable to that I never received payment therefore and that I never received directly or indirectly any benefit therefrom* To induce Western Union to refund to me the face amount of the above Money Order and in consideration of that payment I authorize Western Union to stop payment on this Money Order and agree to reimburse Western Union for this refund and to hold Western Union harmless against any and all expense and/or liability to which it may be subject by reason of this refund to me by reason of my alleged loss of Money Order or by reason of the negotiation of the Money Order.