Risk & Compliance Service Request Form

Company Information:

Organization
CHECK HERE if Third-Party Sender/Third-Party Service Provider
Street Address
PO Box or Suite
City State Zip

Contact Information of Person to Receive Services Contract:

First Name
Last Name
Title
Phone
Email

Contact Information of Person to Receive Pre Service Documents:

First Name
Last Name
Title
Phone
Email
CHECK HERE if information is the same

Contact Information of Secondary Person to Receive Pre-Service Documents:

First Name
Last Name
Title
Phone
Email

Services Requested:

ACH Audit

ACH Risk Assessment

Third-Party ACH Audit

Third-Party ACH Risk Assessment

 Pricing for ACH Audit and ACH Risk Assessment is based on number of ACH Originators/Third-Party Senders.
 Number of ACH Originators
 Number of Third-Party Senders
 SEC Codes Originated

RDC Assessment & Audit of Internal Controls

 RDC Methods Offered:
 Teller/Branch Capture
 Mobile Capture
 ATM Capture
 Merchant Capture
 Pricing for the RDC service is based on number of merchant customers.
 Number of Merchant Capture Customers
 Number of Merchant Mobile Customers

Wire Transfer Assessment & Audit of Internal Controls

 Pricing for Wire service is based on methods and complexity.
 Average Monthly Wire Volume (enter value not dollar amount)
 Wire Methods Offered:
 Email
 Phone
 Fax
 In-Person
 Online Banking/Cash Management
Must comply with Regulation E, Subpart B

Consulting Service*

 Describe customized consulting request*

Additional Information:

CHECK HERE if interested in having services completed remotely
CHECK HERE if interested in signing a multiple year services contract. Two and three year contracts are available. PaymentsFirst will contact you to discuss details of multi-year services contract
CHECK HERE if you are only requesting a proposal. Please provide an email address to which the service proposal should be sent

Preferred Month for Services: Please list preferred months for requested services. PaymentsFirst will contact you shortly to schedule specific days for the month you requested service. Each service selected will take at least one day. Additional days may be needed depending on the complexity of services you offer. When selecting your preferred months for service, please keep in mind that it will take approximately 45 banking days for final reports to be returned to you. Scheduling is based on a first-come, first-served basis. Third and fourth quarters book up very quickly. If you wait to schedule and want dates in third or fourth quarter, it is likely there will not be any available dates.

1st Choice of Month
2nd Choice of Month
3rd Choice of Month
   - denotes required fields