Form M0014 - Money Order Transaction Report - 2015
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1MEMO Financial Services, Inc.
MEMO Financial Services America, Inc.
MEMO Financial Services New York, Inc.
MEMO Financial Services USA, Inc.
MONEY ORDER TRANSACTION REPORT
To Be Completed At Time Of Sale
For Money Order Sales $3,000.00 up to $10,000.00
PURCHASER INFORMATION
AGENCY INFORMATION
__________________________________
______________________________
Name:
Agent ID #:
__________________________________
______________________________
Address:
Agent Name:
__________________________________
______________________________
Agent Address:
________________________________
______________________________
Date of Birth:
______________________________
Occupation: ___________________________________________
Agent Signature:
_________________________ Date of Purchase: ________________________
Social Security/ Alien ID #:
Driver’s License # _______________________________ OFAC Check:
□ YES
□ NO
□ Passport;
□ Other (Please Identify) __________________________
Other ID TYPE (must be photo ID):
ID ISSUER and NUMBER (State/Government – Ex: PA 123456789): _________________________________________________
MONEY ORDER INFORMATION
Serial Number of Money Order
Amount of MO
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
______________________________
$_______________
_________________
: $
TOTAL AMOUNT OF SALE
(If additional space is needed, please use an additional form and attach to this form.)
FAX A COPY OF THE COMPLETED FORM TO MEMO
FINANCIAL SERVICES, INC. TO 717-214-5966.
FEDERAL LAW REQUIRES YOUR BUSINESS TO KEEP A COPY OF THIS DOCUMENT FOR 5 YEARS.
PRIVACY POLICY: This business does not disclose any nonpublic personal information about money order purchasers to any
company, person, or individual except to MEMO or as otherwise required by law. This business restricts access to this document and
its contents to those who need to know the information to facilitate the money order purchase or other lawful purpose. This business
maintains information safeguards that comply with all federal laws and regulations relating to the protection of nonpublic personal
information.
M0014 10/15
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