Payment Card Industry (PCI)
Data Security Standard

Self-Assessment Questionnaire A
and Attestation of Compliance

Card-not-present Merchants,
All Cardholder Data Functions Fully Outsourced
For use with PCI DSS Version 3.2
Revision 1.1
January 2017

Document Changes
Date

PCI DSS
Version

SAQ
Revision

October 2008

1.2

To align content with new PCI DSS v1.2 and to
implement minor changes noted since original v1.1.

October 2010

2.0

To align content with new PCI DSS v2.0 requirements
and testing procedures.

February 2014

3.0

To align content with PCI DSS v3.0 requirements andtesting procedures and incorporate additional response
options.

April 2015

3.1

July 2015

3.1

1.1

Updated version numbering to align with other SAQs.

April 2016

3.2

1.0

Updated to align with PCI DSS v3.2. For details of PCI
DSS changes, see PCI DSS – Summary of Changes
from PCI DSS Version 3.1 to 3.2.

Description

Updated to align with PCI DSS v3.1. For details of PCI
DSS changes, see PCI DSS – Summary of Changes
from PCI DSS Version 3.0 to 3.1.

Requirements added from PCI DSS v3.2 Requirements
2, 8, and 12.
January 2017

3.2

1.1

Updated Document Changes to clarify requirements
added in the April 2016 update.
Added note to Before You Begin section to clarify intent
of inclusion of PCI DSS Requirements 2 and 8.

PCI DSS v3.2 SAQ A, Rev. 1.1© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
Page iTable of ContentsDocument Changes .................................................................................................................. i
Before You Begin .....................................................................................................................iii
PCI DSS Self-Assessment Completion Steps ...................................................................................... iv
Understanding the Self-Assessment Questionnaire ........................................................................... iv
Expected Testing ................................................................................................................................... iv
Completing the Self-Assessment Questionnaire .................................................................................. v
Guidance for Non-Applicability of Certain, Specific Requirements .................................................... v
Legal Exception.................................................................................................................................... v

Section 1: Assessment Information ..................................................................................... 1
Section 2: Self-Assessment Questionnaire A...................................................................... 4
Build and Maintain a Secure Network and Systems ............................................................................. 4
Requirement 2:

Do not use vendor-supplied defaults for system passwords and other security
parameters .................................................................................................................. 4

Implement Strong Access Control Measures ........................................................................................ 5
Requirement 8:

Identify and authenticate access to system components ........................................... 5

Requirement 9:

Restrict physical access to cardholder data ............................................................... 6

Maintain an Information Security Policy ................................................................................................ 8
Requirement 12: Maintain a policy that addresses information security for all personnel ..................... 8
Appendix A: Additional PCI DSS Requirements ............................................................................... 10
Appendix A1:

Additional PCI DSS Requirements for Shared Hosting Providers ............................ 10

Appendix A2:

Additional PCI DSS Requirements for Entities using SSL/early TLS ....................... 10

Appendix A3:

Designated Entities Supplemental Validation (DESV) .............................................. 10

Appendix B: Compensating Controls Worksheet .............................................................................. 11
Appendix C: Explanation of Non-Applicability................................................................................... 12

Section 3: Validation and Attestation Details .....................................................................13

PCI DSS v3.2 SAQ A, Rev. 1.1© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
Page ii

Before You Begin
SAQ A has been developed to address requirements applicable to merchants whose cardholder data
functions are completely outsourced to validated third parties, where the merchant retains only paper
reports or receipts with cardholder data.
SAQ A merchants may be either e-commerce or mail/telephone-order merchants (card-not-present), anddo not store, process, or transmit any cardholder data in electronic format on their systems or premises.
SAQ A merchants confirm that, for this payment channel:Your company accepts only card-not-present (e-commerce or mail/telephone-order) transactions;All processing of cardholder data is entirely outsourced to PCI DSS validated third-party service
providers;Your company does not electronically store, process, or transmit any cardholder data on yoursystems or premises, but relies entirely on a third party(s) to handle all these functions;Your company has confirmed that all third party(s) handling storage, processing, and/ortransmission of cardholder data are PCI DSS compliant; andAny cardholder data your company retains is on paper (for example, printed reports or receipts),
and these documents are not received electronically.

Additionally, for e-commerce channels:All elements of the payment page(s) delivered to the consumer’s browser originate only and directlyfrom a PCI DSS validated third-party service provider(s).
This SAQ is not applicable to face-to-face channels.

This shortened version of the SAQ includes questions that apply to a specific type of small merchantenvironment, as defined in the above eligibility criteria. If there are PCI DSS requirements applicable toyour environment that are not covered in this SAQ, it may be an indication that this SAQ is not suitable foryour environment. Additionally, you must still comply with all applicable PCI DSS requirements in order tobe PCI DSS compliant.
Note: For this SAQ, PCI DSS Requirements that address the protection of computer systems (forexample, Requirements 2 and 8) apply to e-commerce merchants that redirect customers from theirwebsite to a third party for payment processing, and specifically to the merchant webserver upon which
the redirection mechanism is located. Mail order/telephone order (MOTO) or e-commerce merchants thathave completely outsourced all operations (where there is no redirection mechanism from the merchantto the third party) and therefore do not have any systems in scope for this SAQ, would consider theserequirements to be “not applicable.” Refer to guidance on the following pages for how to reportrequirements that are not applicable.

PCI DSS v3.2 SAQ A, Rev. 1.1© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
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PCI DSS Self-Assessment Completion Steps
1. Identify the applicable SAQ for your environment – refer to the Self-Assessment Questionnaire
Instructions and Guidelines document on PCI SSC website for information.
2. Confirm that your environment is properly scoped and meets the eligibility criteria for the SAQ you
are using (as defined in Part 2g of the Attestation of Compliance).
3. Assess your environment for compliance with applicable PCI DSS requirements.
4. Complete all sections of this document:Section 1 (Parts 1 & 2 of the AOC) – Assessment Information and Executive Summary.

Section 2 – PCI DSS Self-Assessment Questionnaire (SAQ A)Section 3 (Parts 3 & 4 of the AOC) – Validation and Attestation Details and Action Plan for
Non-Compliant Requirements (if applicable)

5. Submit the SAQ and Attestation of Compliance (AOC), along with any other requested
documentation—such as ASV scan reports—to your acquirer, payment brand or other requester.

Understanding the Self-Assessment Questionnaire
The questions contained in the “PCI DSS Question” column in this self-assessment questionnaire arebased on the requirements in the PCI DSS.
Additional resources that provide guidance on PCI DSS requirements and how to complete the selfassessment questionnaire have been provided to assist with the assessment process. An overview ofsome of these resources is provided below:
Document

Includes:PCI DSS

Guidance on Scoping(PCI Data Security Standard
Requirements and Security Assessment
Procedures)

Guidance on the intent of all PCI DSS Requirements



Details of testing procedures



Guidance on Compensating Controls

SAQ Instructions and Guidelines
documents



Information about all SAQs and their eligibility criteria

How to determine which SAQ is right for yourorganization

PCI DSS and PA-DSS Glossary ofTerms, Abbreviations, and Acronyms

Descriptions and definitions of terms used in the PCI
DSS and self-assessment questionnaires

These and other resources can be found on the PCI SSC website (www.pcisecuritystandards.org).
Organizations are encouraged to review the PCI DSS and other supporting documents before beginning
an assessment.

Expected Testing
The instructions provided in the “Expected Testing” column are based on the testing procedures in the
PCI DSS, and provide a high-level description of the types of testing activities that should be performed inorder to verify that a requirement has been met. Full details of testing procedures for each requirement
can be found in the PCI DSS.

PCI DSS v3.2 SAQ A, Rev. 1.1© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
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Completing the Self-Assessment Questionnaire
For each question, there is a choice of responses to indicate your company’s status regarding that
requirement. Only one response should be selected for each question.
A description of the meaning for each response is provided in the table below:
Response

When to use this response:

Yes

The expected testing has been performed, and all elements of therequirement have been met as stated.

Yes with CCW

The expected testing has been performed, and the requirement has
been met with the assistance of a compensating control.

(Compensating
Control Worksheet)

All responses in this column require completion of a Compensating
Control Worksheet (CCW) in Appendix B of the SAQ.
Information on the use of compensating controls and guidance on how
to complete the worksheet is provided in the PCI DSS.

No

Some or all elements of the requirement have not been met, or are in
the process of being implemented, or require further testing before it will
be known if they are in place.

N/A

The requirement does not apply to the organization’s environment. (See
Guidance for Non-Applicability of Certain, Specific Requirements below
for examples.)(Not Applicable)

All responses in this column require a supporting explanation in
Appendix C of the SAQ.

Guidance for Non-Applicability of Certain, Specific Requirements
If any requirements are deemed not applicable to your environment, select the “N/A” option for thatspecific requirement, and complete the “Explanation of Non-Applicability” worksheet in Appendix C foreach “N/A” entry.

Legal Exception
If your organization is subject to a legal restriction that prevents the organization from meeting a PCI DSS
requirement, check the “No” column for that requirement and complete the relevant attestation in Part 3.

PCI DSS v3.2 SAQ A, Rev. 1.1© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
Page v

Section 1: Assessment Information
Instructions for Submission
This document must be completed as a declaration of the results of the merchant’s self-assessment with the
Payment Card Industry Data Security Standard Requirements and Security Assessment Procedures (PCI
DSS). Complete all sections: The merchant is responsible for ensuring that each section is completed by therelevant parties, as applicable. Contact acquirer (merchant bank) or the payment brands to determine reportingand submission procedures.

Part 1. Merchant and Qualified Security Assessor Information
Part 1a. Merchant Organization Information
Company Name:

DBA (doing
business as):Contact Name:

Title:

Telephone:

E-mail:Business Address:

City:

State/Province:

Country:

Zip:

URL:

Part 1b. Qualified Security Assessor Company Information (if applicable)
Company Name:
Lead QSA Contact Name:

Title:

Telephone:

E-mail:Business Address:

City:

State/Province:

Country:

Zip:

URL:

Part 2. Executive Summary
Part 2a. Type of Merchant Business (check all that apply)
Retailer

Telecommunication

Grocery and Supermarkets

Petroleum

E-Commerce

Mail order/telephone order (MOTO)

Others (please specify):
What types of payment channels does your businessserve?

Which payment channels are covered by this SAQ?

Mail order/telephone order (MOTO)

Mail order/telephone order (MOTO)

E-Commerce

E-Commerce

Card-present (face-to-face)

Card-present (face-to-face)Note: If your organization has a payment channel or process that is not covered by this SAQ, consult youracquirer or payment brand about validation for the other channels.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 1: Assessment Information© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
Page 1

Part 2b. Description of Payment Card BusinessHow and in what capacity does your businessstore, process and/or transmit cardholder data?

Part 2c. Locations
List types of facilities (for example, retail outlets, corporate offices, data centers, call centers, etc.) and asummary of locations included in the PCI DSS review.
Number of facilitiesof this typeType of facility
Example: Retail outlets

Location(s) of facility (city, country)

3

Boston, MA, USA

Part 2d. Payment Application
Does the organization use one or more Payment Applications?

Yes

No

Provide the following information regarding the Payment Applications your organization uses:
Payment Application
Name

VersionNumber

Application
VendorIs application
PA-DSS Listed?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

PA-DSS Listing Expiry
date (if applicable)

Part 2e. Description of Environment
Provide a high-level description of the environment covered bythis assessment.
For example:• Connections into and out of the cardholder data environment(CDE).
• Critical system components within the CDE, such as POS
devices, databases, web servers, etc., and any othernecessary payment components, as applicable.
Does your business use network segmentation to affect the scope of your PCI DSS
environment?
(Refer to “Network Segmentation” section of PCI DSS for guidance on network
segmentation)
PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 1: Assessment Information© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

Yes

No

January 2017
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Part 2f. Third-Party Service Providers
Does your company use a Qualified Integrator & Reseller (QIR)?

Yes

No

Yes

No

If Yes:Name of QIR Company:

QIR Individual Name:
Description of services provided by QIR:
Does your company share cardholder data with any third-party service providers (forexample, Qualified Integrator & Resellers (QIR), gateways, payment processors, payment
service providers (PSP), web-hosting companies, airline booking agents, loyalty program
agents, etc.)?
If Yes:Name of service provider:

Description of services provided:

Note: Requirement 12.8 applies to all entities in this list.

Part 2g. Eligibility to Complete SAQ A
Merchant certifies eligibility to complete this shortened version of the Self-Assessment Questionnaire
because, for this payment channel:
Merchant accepts only card-not-present (e-commerce or mail/telephone-order) transactions);
All processing of cardholder data is entirely outsourced to PCI DSS validated third-party service
providers;
Merchant does not electronically store, process, or transmit any cardholder data on merchant systems
or premises, but relies entirely on a third party(s) to handle all these functions;
Merchant has confirmed that all third party(s) handling storage, processing, and/or transmission of
cardholder data are PCI DSS compliant; andAny cardholder data the merchant retains is on paper (for example, printed reports or receipts), andthese documents are not received electronically.
Additionally, for e-commerce channels:
All elements of the payment page(s) delivered to the consumer’s browser originate only and directlyfrom a PCI DSS validated third-party service provider(s).

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 1: Assessment Information© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
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Section 2: Self-Assessment Questionnaire A
Note: The following questions are numbered according to PCI DSS requirements and testing procedures, as defined in the PCI DSS
Requirements and Security Assessment Procedures document.
Self-assessment completion date:

Build and Maintain a Secure Network and Systems
Requirement 2: Do not use vendor-supplied defaults for system passwords and other security parameters
Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)
Yes

2.1(a) Are vendor-supplied defaults always changed
before installing a system on the network?



Review policies and proceduresExamine vendor documentation

This applies to ALL default passwords, including but
not limited to those used by operating systems,
software that provides security services, applicationand system accounts, point-of-sale (POS) terminals,
payment applications, Simple Network Management
Protocol (SNMP) community strings, etc.).

Observe system configurations andaccount settingsInterview personnel(b) Are unnecessary default accounts removed or
disabled before installing a system on the
network?



Review policies and procedures



Review vendor documentation

Examine system configurations andaccount settingsInterview personnel

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

Yes with
CCW

No

N/A

January 2017
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Implement Strong Access Control Measures
Requirement 8: Identify and authenticate access to system components
Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)
Yes

8.1.1

8.1.3

Are all users assigned a unique ID before allowing
them to access system components or cardholder
data?



Review password proceduresInterview personnel

Is access for any terminated users immediately
deactivated or removed?



Review password proceduresExamine terminated users accounts



Review current access lists

Observe returned physicalauthentication devices



Review password procedures

Observe authentication processes

Examine system configuration settings
to verify password parameters

In addition to assigning a unique ID, is one or more of
the following methods employed to authenticate allusers?

8.2

8.2.3



Something you know, such as a password or
passphraseSomething you have, such as a token device orsmart card

Something you are, such as a biometric(a) Are user password parameters configured torequire passwords/passphrases meet thefollowing?

Yes with
CCW

No

N/A



A minimum password length of at least
seven charactersContain both numeric and alphabetic
characters
Alternatively, the passwords/passphrases must havecomplexity and strength at least equivalent to theparameters specified above.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
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Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)Yes

8.5

Are group, shared, or generic accounts, passwords, orother authentication methods prohibited as follows:

Review policies and proceduresExamine user ID lists



Generic user IDs and accounts are disabled or
removed;

Interview personnelShared user IDs for system administration
activities and other critical functions do not exist;and

Shared and generic user IDs are not used toadminister any system components?

Yes with
CCW

No

N/A

Requirement 9: Restrict physical access to cardholder data
Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)
Yes

Are all media physically secured (including but notlimited to computers, removable electronic media,
paper receipts, paper reports, and faxes)?

9.5



Review policies and procedures forphysically securing media

Interview personnel



Review policies and procedures for
distribution of media



Review policies and procedures formedia classification

Interview security personnel

Yes with
CCW

No

N/A

For purposes of Requirement 9, “media” refers to all
paper and electronic media containing cardholder
data.
(a) Is strict control maintained over the internal orexternal distribution of any kind of media?

9.6(b) Do controls include the following:

9.6.1

Is media classified so the sensitivity of the data can be
determined?

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
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Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)Yes

Is media sent by secured courier or other delivery
method that can be accurately tracked?

Interview personnel

Examine media distribution tracking
logs and documentation

Is management approval obtained prior to moving themedia (especially when media is distributed toindividuals)?

Interview personnel

Examine media distribution tracking
logs and documentation

9.7

Is strict control maintained over the storage andaccessibility of media?



Review policies and procedures

9.8(a) Is all media destroyed when it is no longer needed
for business or legal reasons?



Review periodic media destruction
policies and procedures



Review periodic media destruction
policies and proceduresInterview personnel

Observe processes

Examine security of storage
containers

9.6.2

9.6.3

Yes with
CCW

No

N/A

(c) Is media destruction performed as follows:

9.8.1(a) Are hardcopy materials cross-cut shredded,
incinerated, or pulped so that cardholder datacannot be reconstructed?

(b) Are storage containers used for materials that
contain information to be destroyed secured toprevent access to the contents?

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Maintain an Information Security Policy
Requirement 12:

Maintain a policy that addresses information security for all personnel

Note: For the purposes of Requirement 12, “personnel” refers to full-time part-time employees, temporary employees and personnel, andcontractors and consultants who are “resident” on the entity’s site or otherwise have access to the company’s site cardholder data environment.
Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)
Yes

12.8

12.8.112.8.2

Yes with
CCW

No

N/A

Are policies and procedures maintained andimplemented to manage service providers with whom
cardholder data is shared, or that could affect the
security of cardholder data, as follows:
Is a list of service providers maintained, including adescription of the service(s) provided?

Is a written agreement maintained that includes an
acknowledgement that the service providers are
responsible for the security of cardholder data theservice providers possess or otherwise store, process,or transmit on behalf of the customer, or to the extent
that they could impact the security of the customer’s
cardholder data environment?



Review policies and procedures

Observe processes



Review list of service providers



Observe written agreements



Review policies and procedures

Observe processes



Review policies and procedures andsupporting documentation

Note: The exact wording of an acknowledgement will
depend on the agreement between the two parties, thedetails of the service being provided, and the
responsibilities assigned to each party. The
acknowledgement does not have to include the exact
wording provided in this requirement.

12.8.3Is there an established process for engaging service
providers, including proper due diligence prior to
engagement?

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Response
PCI DSS Question

Expected Testing(Check one response for eachquestion)Yes

12.8.412.8.512.10.1

Is a program maintained to monitor service providers’
PCI DSS compliance status at least annually?

Observe processes



Review policies and procedures andsupporting documentation

Is information maintained about which PCI DSS
requirements are managed by each service provider,and which are managed by the entity?



Observe processes



Review policies and procedures andsupporting documentation(a) Has an incident response plan been created to be
implemented in the event of system breach?



Review the incident response plan

Review incident response plan
procedures

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

Yes with
CCW

No

N/A

January 2017
Page 9Appendix A: Additional PCI DSS Requirements
Appendix A1:

Additional PCI DSS Requirements for Shared Hosting Providers

This appendix is not used for merchant assessments.

Appendix A2:

Additional PCI DSS Requirements for Entities using SSL/early TLS

This appendix is not used for SAQ A merchant assessments

Appendix A3:

Designated Entities Supplemental Validation (DESV)This Appendix applies only to entities designated by a payment brand(s) or acquirer as requiring
additional validation of existing PCI DSS requirements. Entities required to validate to this Appendix
should use the DESV Supplemental Reporting Template and Supplemental Attestation of Compliance forreporting, and consult with the applicable payment brand and/or acquirer for submission procedures.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Appendix B: Compensating Controls Worksheet
Use this worksheet to define compensating controls for any requirement where “YES with CCW” waschecked.
Note: Only companies that have undertaken a risk analysis and have legitimate technological or
documented business constraints can consider the use of compensating controls to achieve compliance.
Refer to Appendices B, C, and D of PCI DSS for information about compensating controls and guidanceon how to complete this worksheet.
Requirement Number and Definition:
Information Required
1. Constraints

List constraints precluding compliancewith the original requirement.

2. Objective

Define the objective of the originalcontrol; identify the objective met by
the compensating control.

3. Identified Risk

Identify any additional risk posed by thelack of the original control.

4. Definition ofCompensating
Controls

Define the compensating controls andexplain how they address theobjectives of the original control andthe increased risk, if any.

5. Validation ofCompensating
Controls

Define how the compensating controls
were validated and tested.

6. MaintenanceDefine process and controls in place tomaintain compensating controls.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

Explanation

January 2017
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Appendix C: Explanation of Non-Applicability
If the “N/A” (Not Applicable) column was checked in the questionnaire, use this worksheet to explain why
the related requirement is not applicable to your organization.
Requirement

Reason Requirement is Not Applicable

Example:3.4

Cardholder data is never stored electronically

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 2: Self-Assessment Questionnaire© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Section 3: Validation and Attestation Details
Part 3. PCI DSS Validation
This AOC is based on results noted in SAQ A (Section 2), dated (SAQ completion date).
Based on the results documented in the SAQ A noted above, the signatories identified in Parts 3b-3d, asapplicable, assert(s) the following compliance status for the entity identified in Part 2 of this document:(check one):
Compliant: All sections of the PCI DSS SAQ are complete, all questions answered affirmatively,
resulting in an overall COMPLIANT rating; thereby (Merchant Company Name) has demonstrated fullcompliance with the PCI DSS.
Non-Compliant: Not all sections of the PCI DSS SAQ are complete, or not all questions are answered
affirmatively, resulting in an overall NON-COMPLIANT rating, thereby (Merchant Company Name) has
not demonstrated full compliance with the PCI DSS.
Target Date for Compliance:
An entity submitting this form with a status of Non-Compliant may be required to complete the Action
Plan in Part 4 of this document. Check with your acquirer or the payment brand(s) before completing
Part 4.
Compliant but with Legal exception: One or more requirements are marked “No” due to a legal
restriction that prevents the requirement from being met. This option requires additional review fromacquirer or payment brand.
If checked, complete the following:
Affected Requirement

Details of how legal constraint prevents requirement being met

Part 3a. Acknowledgement of Status
Signatory(s) confirms:(Check all that apply)

PCI DSS Self-Assessment Questionnaire A, Version (version of SAQ), was completed according to the
instructions therein.
All information within the above-referenced SAQ and in this attestation fairly represents the results ofmy assessment in all material respects.
I have confirmed with my payment application vendor that my payment system does not store sensitive
authentication data after authorization.
I have read the PCI DSS and I recognize that I must maintain PCI DSS compliance, as applicable to
my environment, at all times.
If my environment changes, I recognize I must reassess my environment and implement any additional
PCI DSS requirements that apply.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 3: Validation and Attestation Details© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Part 3a. Acknowledgement of Status (continued)
No evidence of full track data1, CAV2, CVC2, CID, or CVV2 data2, or PIN data3 storage after
transaction authorization was found on ANY system reviewed during this assessment.
ASV scans are being completed by the PCI SSC Approved Scanning Vendor (ASV Name)

Part 3b. Merchant Attestation

Signature of Merchant Executive Officer 

Date:Merchant Executive Officer Name:

Title:Part 3c. Qualified Security Assessor (QSA) Acknowledgement (if applicable)
If a QSA was involved or assisted with thisassessment, describe the role performed:

Signature of Duly Authorized Officer of QSA Company 

Date:

Duly Authorized Officer Name:QSA Company:

Part 3d. Internal Security Assessor (ISA) Involvement (if applicable)
If an ISA(s) was involved or assisted with thisassessment, identify the ISA personnel anddescribe the role performed:

1

Data encoded in the magnetic stripe or equivalent data on a chip used for authorization during a card-present transaction. Entities
may not retain full track data after transaction authorization. The only elements of track data that may be retained are primaryaccount number (PAN), expiration date, and cardholder name.

2

The three- or four-digit value printed by the signature panel or on the face of a payment card used to verify card-not-present
transactions.

3

Personal identification number entered by cardholder during a card-present transaction, and/or encrypted PIN block present
within the transaction message.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 3: Validation and Attestation Details© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

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Part 4. Action Plan for Non-Compliant Requirements
Select the appropriate response for “Compliant to PCI DSS Requirements” for each requirement. If you
answer “No” to any of the requirements, you may be required to provide the date your Company expects to becompliant with the requirement and a brief description of the actions being taken to meet the requirement.
Check with your acquirer or the payment brand(s) before completing Part 4.

PCI DSS
Requirement*

Description of Requirement

Compliant to PCI
DSS Requirements(Select One)
YES

2

Remediation Date and Actions(If “NO” selected for any
Requirement)NO

Do not use vendor-supplieddefaults for system passwords andother security parameters

8

Identify and authenticate access tosystem components

9

Restrict physical access to
cardholder data

12

Maintain a policy that addresses
information security for all
personnel* PCI DSS Requirements indicated here refer to the questions in Section 2 of the SAQ.

PCI DSS v3.2 SAQ A, Rev. 1.1 – Section 3: Validation and Attestation Details© 2006-2017 PCI Security Standards Council, LLC. All Rights Reserved.

January 2017
Page 15