MONEYGRAM PAYMENT SYSTEMS, INC.

6701 PARKWAY CIRCLE, MAIL STATION MBC-0023

BROOKLYN CENTER, MN 55430

DEAR MONEY ORDER CUSTOMER:

PER YOUR RECENT REQUEST, BELOW IS THE INFORMATION MONEYGRAM WILL NEED TO FILE A
CLAIM ON YOUR BEHALF. PLEASE KEEP IN MIND, IT IS UP TO THE BANK THAT FIRST DEPOSITED THE
MONEY ORDER TO DETERMINE WHETHER IT IS OBLIGATED TO PAY YOUR CLAIM.
MONEYGRAM HAS A LIMITED AMOUNT OF TIME TO NOTIFY THE BANK THAT ORIGINALLY
DEPOSITED THE MONEY ORDER, AND WE WILL NEED THE FOLLOWING ITEMS IN ORDER TO
SEND A CLAIM ON YOUR BEHALF:
_____1. The enclosed affidavit form must be COMPLETED AND SIGNED IN THE PRESENCE OF A NOTARY
PUBLIC (if outside of the United States of America, THERE MUST BE A CONSULATE STAMP. The Bank
may refuse to research this affidavit if it does not bear a notary or consulate stamp.)
_____2. Please include a copy of the original money order receipt stub if available.
_____3. If law enforcement has been involved, please provide a copy of your police report.
_____4. You must send a $35.00 NON-REFUNDABLE FEE, for each item being processed. Please pay with a money
order made payable to: MONEYGRAM PAYMENT SYSTEMS, INC.
_____5. Affidavits must BE COMPLETED AND RETURNED TO US WITHIN 60 DAYS from the date you
contacted us. If your affidavit and fee are not returned within 60 DAYS, our file on your claim will be closed.
_____6. Please inform us of any address changes by writing to the address at the top of this letter. Please reference the
10 digit money order number on all future correspondence.
If you have any questions regarding the completion of the affidavit, please call our customer service department at 1-800542-3590.
THE FILING OF YOUR AFFIDAVIT WILL NOT TAKE PLACE WITHOUT THE FOLLOWING ITEMS:
ORIGINAL AFFIDAVIT SIGNED AND NOTARIZED
A $35.00 PROCESSING FEE PER ITEM
Upon receipt of your information, we will forward the affidavit to the bank that originally deposited the money order.
The bank will then research your request and respond. This process may take 3-6 months or longer once received by
MoneyGram and we will notify you when we receive a response. Please do not call prior to 120 days after your claim is
filed.
NOTE: THIS AFFIDAVIT DOES NOT GUARANTEE A REFUND WILL BE ISSUED AND MAILED TO YOU.
THE COLLECTABILITY OF YOUR CLAIM WILL BE DETERMINED BY THE BANK OF FIRST DEPOSIT.

INSTRUCTIONS FOR COMPLETING THE AFFIDAVIT

1. Fill out the Money Order Number and Amount at the top of the form. MoneyGram will complete the Cleared Date.
2. Please read all choices in items A through E before completing this affidavit. Select ONLY ONE of the reasons
listed (according to the guidelines below) and complete all required information on the affidavit form:
A- The Pay to the Order line on the front of the Money Order had:
Information removed
Information crossed out
Information changed
Information added
If any of these scenarios apply, choose Payee Name Altered (Only check this box on the affidavit).
B- The Purchaser, signer for drawer line on the front of the Money Order had:
Information removed
Information crossed out
Information changed
Information added
If any of these scenarios apply, choose Purchaser name Altered. (Only check this box on the affidavit).
C- Both the Pay to the Order line and the Purchaser, signer for drawer line on front of the Money Order
had:
Information removed
Information crossed out
Information changed
Information added
If any of these scenarios apply, choose Payee Name and Purchaser Name was both Altered. (Only check this
box on the affidavit).
D- The signature on the back of the Money Order does not belong to the payee or purchaser of the Money Order.
Indicate Endorsement Forged on the affidavit, indicating the purchaser and /or payee name on the space
provided (Only check this box on the affidavit). The name must be the payee or purchaser name on the Money
Order. The persons name that was forged must sign the affidavit. PLEASE NOTE: If the payee or the
purchaser signed the back of the Money Order, it is not a forged endorsement. Do not indicate endorsement
forged on affidavit.
E- If the back of the Money Order does not indicate any signature (endorsement), indicate Not Endorsed by Payee
on the affidavit.
If made payable from you to another person, the person whose name appears on the Pay to the Order
line must sign the affidavit.
If the Money Order is made payable from you to a business and there is no type of endorsement, of any kind,
on the back of the Money Order, the purchaser must sign the affidavit. The purchaser will receive the
refund.
If the Money Order is made payable from you to a business, and there is an endorsement on the back of the
Money Order, send the affidavit to the business and have a representative of that company sign the
affidavit stating they did not cash the Money Order. Have them include their name and title.
If made payable to a business and a stamp appears indicating Credit to the within named Payee, Payment
Guaranteed, this indicates that the business received the funds but applied the funds incorrectly. Send the
photo of the items to the business for proof of payment and do not return this affidavit to MoneyGram.

Affidavit for Improperly Negotiated MoneyGram Money Order

Cleared Date (Office use only)
Money Order Number (required)
Amount (required)
$
Please TYPE or PRINT clearly. Check ONLY ONE box below that best describes your claim. The person making the
claim must sign this form in front of a Notary Public. Please do not select more than one box, cross out anything or use
white out on this page. Completion of this affidavit does NOT GUARANTEE a refund will be issued to you.
Payee Name Altered
The money order was originally made payable to ______________________________ and was altered or
changed to make it payable to the order of _____________________________. I did not alter the payees name
nor authorize the alteration. The purchaser must sign this affidavit. The purchaser will receive the refund.
Purchaser Name Altered
The original purchasers name was altered or changed to _________________________. I did not alter the
purchasers name. The purchaser must sign this affidavit. The purchaser will receive the refund.
Payee Name and Purchaser Name were both Altered
The money order was originally made payable to _______________________ and was altered or changed to
make it payable to the order of ___________________________. The original purchasers name was altered or
changed to _______________________. I did not alter either of the purchasers or payees name nor authorize the
alteration. The purchaser must sign this affidavit. The purchaser will receive the refund.
Endorsement Forged
The endorsement of ________________________________ on the above item is a forgery. I did not authorize or
write the endorsement. The person whose name was forged must sign the affidavit. The person signing this form
will receive the refund.
Not Endorsed by Payee (If selected, please check one of the boxes below)
Money order was payable to a person. The money order does not bear the endorsement of the payee and the
payee has not benefited in any way by the issuance of this money order. The party to whom the money order
was payable to must sign this affidavit, but the purchaser will receive the refund.
Money order was payable to a business. The money order does not bear the endorsement of the business and
did not benefit in any way by the issuance of this money order. The business representative to whom the
money order was payable to must sign this affidavit, but the purchaser will receive the refund.
AFFIDAVIT FOR IMPROPERLY NEGOTIATED MONEYGRAM MONEY ORDER
I have not benefited in any way by the issuance or negotiation of said money order.
Notary or Consulate Seal use only
______________________________________________
(SIGNATURE)
______________________________________________
(PRINT OR TYPE NAME)
_______________________________________________
(PRINT OR TYPE ADDRESS)
_______________________________________________
(PRINT OR TYPE CITY, STATE AND ZIP CODE)
Subscribed and sworn to before me this _________________
Day of_________________________,________________
My commission expires: _________________________
Notary Publics Signature: _________________________
Name (type or printed): _________________________