Western Union Blank Form – Fill Out and Use

Western Union Financial Services, Inc.

PO Box 7030

Englewood, Colorado 80155-703

1-800-999-9660

MONEY ORDER AFFIDAVIT

STATE: __________________________________)

COUNTY: ________________________________)

I, ___________________________________________________ , at__________________________________ and

(Full Legal Name )(Daytime Phone Number)

of __________________________________________________________________________________________,

Financial Services, Inc., or Integrated Payment Systems Inc. (“Money Order”), described below:

Money Order Number:

(11 Digits)

Face Amount of Money Order:

“Purchaser” Name:

(Who purchased the Money Order)*

“Payee” Name

(Who the Money Order is payable to)*

I am requesting this refund on behalf of a

Company. (Yes or No)*

Date and time of Money Order Purchase:

Name and Address of Western Union Agent

Location Where The Money Order was

Purchased

* if the party requesting a refund is a company (e.g. a corporation, LLC, etc.) please also complete page 2.

B)Upon information and belief, the Money Order was _____________________________________________; and

(Lost, destroyed, stolen, etc.)

C)Neither the Purchaser, nor the Payee, has cashed, negotiated, deposited, transferred, received payment or received a benefit of any kind, directly or indirectly, from the Money Order.

THEREFORE: To induce Western Union Financial Services, Inc and/or Integrated Payment Systems Inc. (collectively, “Western Union”) to refund the face amount of the Money Order and in consideration of such payment, I authorize Western Union to issue a stop payment order on the Money Order, and I agree to pay Western Union a $15.00 non-refundable processing fee for this request; I understand that if the Money Order has been paid, I will only receive a copy of the Money Order and not a refund. I agree to indemnify and hold Western Union harmless against any and all damages, costs, expenses and/or liability arising out of, or otherwise connected with, my representations herein, including any actions taken by Western Union in reliance upon such representation, this refund, the Money Order, or as a result of the negotiation of the Money Order.

_________________________________________________________

SignatureDate

Subscribed and sworn to before me this ____________________day of _____________________20_________

Page 1

Western Union Financial Services, Inc.

PO Box 7030

Englewood, Colorado 80155-703

1-800-999-9660

MONEY ORDER AFFIDAVIT-COMPANY ADDENDUM

STATE: __________________________________)

COUNTY: ________________________________)

I, ___________________________________________________, am the __________________________________

(Full Legal Name )(Formal Business Title or Position)

of _______________________________________________________(the “Company”) ,

(Legal Name of Entity)

a ______________________ organized, incorporated or existing under the laws of the state of ________________,

and with its principal place of business located at:

______________________________________________________________________________________,

being duly sworn, do depose and say:

A)I am requesting a refund of the face value of the Money Order, and executing this Affidavit on behalf of the Company; and

B)I have the power and authority to act on Company’s behalf, including the power to request this refund and execute this Affidavit on Company’s behalf; and

C)Neither the Company, nor any person acting on Company’s behalf, has cashed, negotiated, deposited, transferred, received payment or received a benefit of any kind, directly or indirectly, from the Money Order;

________________________________________________________

SignatureDate

Subscribed and sworn to before me this ______________day of ____________________20_________.

My commission expires: ____________________________________.

Page 2