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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 __________________________________________________________________________________________,
Street City State Zip Code
duly sworn, do depose and say:
A) I am the PAYEE / PURCHASER (mark one) of the money order issued by Western Union
Financial Services, Inc., or Integrated Payment Systems Inc. (“Money Order”), described below:
* 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.
_________________________________________________________
Signature Date
Subscribed and sworn to before me this ____________________day of _____________________20_________
My commission expires: ____________________________________
__________________________________________________________
NOTARY PUBLIC (Notary Stamp, if applicable)
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
