Fillable Moneygram Send Form printable pdf download

MoneyGram Send

(Bank sale to customer)

Fraud warning! Stop!

Please read the questions below carefully to help us protect you from becoming a victim of fraud or a scam

Are you sending money:

•

to someone you don’t know or whose identity you cannot verify?

•

to someone at home or overseas who claims to be your relative needing cash

•

to prove to someone that you have the available funds to buy a car, other

for an ‘emergency’ and you are unable to verify independently if the caller and

goods, or to rent a property? Are you being asked by any 3rd party to provide

the claims are genuine?

any details about this transaction in part or in full by phone, email, fax or website?

•

to someone you met in an on-line chat room or dating web site for ﬁ nancial

•

to buy a product, service or a pet via the internet or anywhere else in response

assistance? Examples: airplane ticket, medical bills, helping a relative, cashing

to any offer that sounds very cheap in comparison to their expected price or

a check, investing in a business deal, etc.

looks ’too good to be true’?

•

to buy goods and services from someone who speciﬁ cally recommends money

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to claim lottery or prize winnings, inheritance, for a ‘guaranteed’ credit card,

transfer through MoneyGram as the preferred mode of payment?

loan offer, refund of bank charges or attractive investments?

If you answered yes to any of these questions, do not send the money transfer–

•

in response to an internet offer, letter or phone call that asks you to send money

someone may be trying to steal your money. Remember neither MoneyGram

for a ‘job offer’ or ‘mystery shopping’ or a ‘charity’?

nor its agents will be liable if you ignore the fraud warnings above and still

choose to send money for any of the reasons listed above.

Branch name

Branch IBT number

Senders details

Date of birth

Surname

(YYYY-MM-DD)

First names

Gender

Identity/ passport or permit type and number

Foreign identity/passport number

Passport country

Full residential address

Postal address

Street 1

Address 1

Street 2

Address 2

Suburb

City

Province

Postal code

Sender’s occupation (If applicable)

Email address

Telephone number

Fax number

Contact name and surname

Transaction details

MoneyGram reference number

Transaction reference number

Account number to be debited

Relationship with recipient

Source of funds

Foreign amount

Exchange rate

Currency

Rand amount

Commisson

VAT

Total amount

Test question

Answer

Beneﬁ ciary details

If used for travel

Beneﬁ ciary’s ﬁ rst names

Ticket reference number

Beneﬁ ciary’s surname

Air line/other mode of transport (Registration number)

Beneﬁ ciary’s address

Departure date

(YYYY-MM-DD)

Receive country, City and State

Border post

BOP category

Return date

(YYYY-MM-DD)

Declaration and Acknowledgement

You, the undersigned, hereby declare that:

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you have read this document and know and understand the contents thereof;

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the information furnished above is in all respects both true and correct;

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the currency applied for will only be used for the speciﬁ c purpose stated herein;

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the documentation presented in support of this application is in all respects authentic;

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you have been informed of the limit applicable to the above transaction and conﬁ rm that this limit will not be exceeded as a result of the conclusion of this

transaction;

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you consent to this information being provided to the South African Revenue Service and/or the Financial Intelligence Centre;

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you have read, understood and agree to be bound by the Terms and Conditions related to the MoneyGram Money Transfer Service on the reverse of this

document to which this transaction is subject;

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you conﬁ rm that you have read and understood the Fraud Warning at the top of this form, that you are NOT sending this Money Transfer for any of the purposes

listed in the Fraud Warnings on this form and that you are not doing anything which you are warned not to do at the top of this form.

•

Moneygram and its agents are not liable for errors, omissions or delays in transmissions arising from circumstances beyond their control;

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MoneyGram and its agents will not be liable for any indirect or consequential loss;

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you authorise Standard Bank to debit the account indicated above with all and any amounts relating to the transaction detailed above; and

•

you will not buy foreign exchange for a third party.

Note: This is our standard form client agreement upon which we intend to rely. For your own beneﬁ t and protection, you should read the terms and conditions which apply to

your transaction on the reverse of the form carefully before signing below. If you do not understand any point please ask for further information.

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The Standard Bank of South Africa Limited (Reg. No. 1962/000738/06) An authorised ﬁ nancial services and registered credit provider (NCRCP15).