Is an electronic signature legally valid?

Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and the Uniform Electronic Transactions Act adopted by most states, electronic signatures are legally equivalent to handwritten signatures when intent, consent, attribution, and record retention requirements are met.

Does the form require notarization or witnesses?

Not usually. The Payment Card Industry Compliance Form itself rarely requires notarization, but state or contractual requirements may impose notary or witness rules for related legal instruments. Verify with your state notary laws and contract terms before assuming no notarization is required.

Can I use Remote Online Notarization (RON)?

Possibly. Many states permit Remote Online Notarization (RON) with identity proofing, audio-video recording, and record retention requirements, but laws differ. Check your state's notary commission rules and ensure RON sessions meet identity and evidence retention standards before relying on remote notarization.

Are eSignatures acceptable for PCI attestations?

Yes, when they meet legal tests of intent, consent, attribution, and retention. Maintain audit trails, signer authentication, and reproductions of signed records. Some acquirers may require additional attestations or formats for formal PCI submissions.

What happens if information is incorrect on the form?

Incorrect or incomplete information can trigger audit findings, require remediation, and may result in fines from card brands or acquirer penalties. Mistakes often lead to repeated requests for evidence and extended assessment timelines.

How do I correct or update a submitted form?

Update the form by creating a new version with a clear change log, obtaining re-attestation from authorized signers, attaching updated evidence, and preserving prior versions for audit history. Notify acquirers or assessors if changes affect prior attestations.

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Payment Card Industry Compliance Form

Payment Card Industry Compliance Form

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Payment Card Industry Compliance Form

This Payment Card Industry Compliance Form documents the representations, scope, controls, and certifications relating to the handling, processing, storage, or transmission of cardholder data by the parties named below and sets forth the compliance obligations and remedies associated with that handling.

Parties

Service Provider - Legal Entity Name Service Provider - Address Client - Legal Entity Name Client - Address

WHEREAS

WHEREAS, Service Provider provides technical services, software, and/or payment processing services that may involve the receipt, storage, processing or transmission of cardholder data; and

WHEREAS, Client engages Service Provider to perform the services described herein and requires that any cardholder data environment and related systems comply with applicable Payment Card Industry Data Security Standard (PCI DSS) requirements; and

WHEREAS, the parties intend to set forth the scope, attestations, remediation responsibilities, reporting obligations, and audit rights necessary to demonstrate and maintain PCI compliance.

Scope of Work

Service Provider shall perform the following services with respect to the cardholder data environment (CDE) and associated systems. Describe the systems, services, or components included within the scope of PCI compliance for this engagement:

Cardholder Data Environment - Primary Locations / Systems

Compliance Details and Attestations

PCI DSS version in effect: Merchant/Entity ID:

PCI Compliance Level (select all that apply): Level 1 Level 2 Level 3 Level 4

Self-Assessment Questionnaire (SAQ) Type:

Qualified Security Assessor (QSA) engaged: Yes If yes, QSA name:

Last Approved External Vulnerability Scan (ASV) Date: Last Penetration Test Date:

Remediation and Compensating Controls

Security Controls and Reporting

Encryption of cardholder data in transit and at rest is implemented as follows:

Quarterly vulnerability scans will be performed by an Approved Scanning Vendor (ASV) and results provided to Client within days of completion.

Payment Terms

Total Fee for PCI Compliance Services Payment Schedule / Milestones

Late payment fee: . Client is responsible for reasonable collection costs and interest permitted by law.

Term and Termination

This agreement commences on: and continues until: unless earlier terminated in accordance with this section.

Either party may terminate for convenience upon days' prior written notice. Either party may terminate immediately for material breach that remains uncured for days after written notice.

Upon termination, Service Provider shall securely return or destroy cardholder data in its possession in accordance with PCI DSS requirements and provide Client written certification of destruction within days.

Confidentiality

Each party shall retain in confidence all cardholder data and any non-public information disclosed by the other party in connection with this agreement. Confidential information shall not be used or disclosed except as necessary to perform obligations under this agreement or as required by law. The obligations in this section shall survive termination for a period of years.

Audit Rights and Cooperation

Client and its authorized agents, including QSAs, shall have the right to audit the Service Provider's relevant systems, facilities, logs and supporting documentation necessary to verify compliance with PCI DSS. Service Provider shall cooperate with such audits and provide reasonable access within days' notice, subject to confidentiality protections.

Indemnification and Limitations

Service Provider agrees to indemnify, defend and hold Client harmless from third-party claims directly resulting from Service Provider's failure to comply with applicable PCI DSS requirements where such failure is the proximate cause of the claim, subject to any limitations set forth in a separate services agreement between the parties.

Governing Law

This agreement shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

Entire Agreement

This form, together with any referenced statements of work or engagement letters executed by the parties, constitutes the entire agreement between the parties with respect to PCI compliance obligations and supersedes all prior and contemporaneous agreements and understandings, whether written or oral, relating to the same subject matter.

Certifications

By signing below, the undersigned authorized representatives certify that the information provided in this form is complete and accurate to the best of their knowledge, that required scans and assessments have been performed as indicated, and that any identified critical deficiencies will be remediated in accordance with the remediation plan set forth above. The undersigned further acknowledges that material misrepresentation may subject the responsible party to corrective action, up to and including termination of services.

Attestations (check all that are true):

Current compliance with PCI DSS ASV scans up to date Penetration tests up to date Remediation plan in place for identified issues

Notices

Primary Contact for Compliance Communications

Service Provider - Printed Name:

By:

Date:

Client - Printed Name:

By:

Date:

What the Payment Card Industry Compliance Form Is

The Payment Card Industry Compliance Form records an entity's procedures and attestation related to handling, storing, and transmitting payment card data to meet PCI DSS obligations and to document controls for audits and business partners. It typically captures company identification, scope of systems, applicable PCI DSS version, implemented security controls, risk-mitigation measures, and responsible signers. Organizations use the form to demonstrate compliance to acquirers, processors, or assessors and to provide a consistent record for internal governance, vendor intake, and incident response. The form supports internal review cycles and evidence collection during PCI assessments and audits.

Why a Standardized PCI Compliance Form Helps Your Program

A Payment Card Industry Compliance Form centralizes evidence of cardholder data protections, clarifies responsibilities, and reduces audit preparation time. It helps organizations identify gaps against PCI DSS requirements, document remediation steps, and provide standardized attestations to acquirers, partners, or external assessors.

Who Typically Completes This Form

Organizations across payments, retail, and services complete the Payment Card Industry Compliance Form to document controls and meet partner or acquirer requirements.

Merchants processing card payments who need to demonstrate PCI DSS alignment and remediation timelines.
Payment service providers or gateways documenting security controls for acquirers, partners, and audits.
Third-party vendors and processors supplying written attestations or scope definitions during vendor assessment.

Internal security, compliance, and operations teams coordinate to provide accurate inputs and maintain the form as a living compliance record.

Essential Sections of a Professional PCI Compliance Form

Core components of a professional Payment Card Industry Compliance Form ensure scope clarity, control evidence, remediation tracking, and authoritative sign-off for audit readiness.

Scope

Define network segments, systems, and third-party services that process, store, or transmit cardholder data. Include IP ranges, cloud services, and any tokenization or payment gateway components in scope.

Security Controls

List implemented PCI DSS control families such as encryption, access controls, logging, vulnerability scanning, and segmentation. Provide evidence references and configuration summaries to support each control claim for assessors.

Assessment Summary

Summarize recent assessment type (self-assessment questionnaire or ROC), findings, scoring, and assessor notes. Include dates, version of PCI DSS referenced, and any compensating controls used.

Remediation Plan

Document identified deficiencies, assigned owners, target completion dates, and status updates. Track verification steps and attach proof of remediation such as patch records or configuration changes.

Authorized Signers

Identify responsible executives or compliance officers authorized to attest on behalf of the organization, including printed name, title, contact, and date of signature to create a clear audit trail.

Supporting Files

Attach network diagrams, scan reports, SIEM logs, policies, vendor PCI letters, and compensating control documentation. Use versioned filenames and reference attachments within the form for traceability.

Security and Compliance Data Elements to Record

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Access Controls: Role-based access and least privilege

Audit Trail: Detailed timestamps, IPs, and actions

HIPAA BAA: Available with signed BAA

Certifications: SOC 2 Type II and ISO 27001

Multi-factor Auth: 2FA and advanced signer authentication

Key Risks and Potential Consequences of Non-Compliance

Card Brand Fines: Significant penalties per breach

Acquirer Penalties: Fees, increased monitoring, termination

Regulatory Notification: State breach laws trigger notices

Contract Breach: Loss of processing agreements

PCI Non-Compliance: Mandatory audits and remediation

Reputational Damage: Customer loss and revenue impact

Common Preparation Mistakes to Avoid

Narrow or vague scope definitions that omit cloud providers or shared services, causing gaps in scans, segmentation, and assessor findings.
Incomplete evidence attachments or use of screenshots without metadata, which weakens assertions and may lengthen remediation and re-assessment cycles.
Unauthorized signers or missing signature dates that invalidate attestations during acquirer review or formal audits.
Failing to update the form after significant environment or vendor changes leaves stale attestations that fail to reflect current controls.

Step-by-Step: Completing the Payment Card Industry Compliance Form

Follow this step-by-step sequence to complete and validate the Payment Card Industry Compliance Form for internal and external review.

01

Gather Information: Collect network diagrams, vendor contracts, and scan reports.
02

Define Scope: Record systems, services, and cardholder data flows.
03

Document Controls: List technical and administrative controls with evidence references.
04

Sign and Archive: Have authorized signer attest and save versioned record.

How eSubmission and Routing Typically Work

Typical routing for the form moves from preparer to compliance, to authorized signers, then to acquirers or assessors for review.

Upload Document: Save final PDF with attachments and upload to platform.
Assign Reviewers: Add compliance and security reviewers with role-based tasks.
Request Signatures: Route to authorized signers; include signer authentication methods.
Send to Acquirer: Transmit completed form and evidence to acquirers or assessors.

Configuring an Electronic Workflow for the Form

Configure an electronic workflow to collect, authenticate, and archive the Payment Card Industry Compliance Form using conditional fields and version control.

Field	Configuration
Authentication	Email and optional SMS or KBA for signer verification.
Conditional Fields	Show remediation fields only when findings present.
Attachments	Require upload of scan reports and vendor PCI letters.
Versioning	Lock previous versions and store audit history.

Platform Features to Support Secure Collection

Ensure the platform supports secure eSignature, audit trails, file attachments, and role-based access to protect PCI-related documentation during collection.

File Formats: PDF, DOCX, and text
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS code, or SSO options

Typical Timelines for Assessments, Scans, and Remediation

Typical compliance timelines for PCI forms align with assessment cycles, vulnerability scanning cadences, and remediation SLAs established by acquirers or PCI DSS requirements.

Annual Assessment Due:

Complete ROC or SAQ annually and record completion date.

Quarterly Scans:

External vulnerability scans must run quarterly and be documented.

Remediation SLA:

Address critical findings within 30 days where practical.

Reassessment After Change:

Reassess scope after material infrastructure or vendor changes.

Evidence Retention:

Keep supporting evidence for audits per retention policies.

Milestones: From Draft to Final Attestation

Key milestones track the form lifecycle from preparation through review, remediation, signature, and submission to external parties for assessment.

01

Preparation Complete

Form drafted and attachments gathered; ready for internal review.

02

Internal Review

Security and compliance teams validate control mappings and evidence.

03

Remediation Closed

Owners resolve findings and upload verification evidence.

04

Final Attestation

Authorized signer dates the form and archives the final version.

Comparison: Common eSignature Plan Features for PCI Forms

Comparison of typical eSignature plans and features relevant when managing the Payment Card Industry Compliance Form and vendor selection for secure attestations.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes — available in Premium/Enterprise	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Payment Card Industry Compliance Form

Answers to frequent questions about completing, eSigning, and legally validating the Payment Card Industry Compliance Form in U.S. contexts.

Need help? Contact support

Is an electronic signature legally valid?
Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and the Uniform Electronic Transactions Act adopted by most states, electronic signatures are legally equivalent to handwritten signatures when intent, consent, attribution, and record retention requirements are met.
Does the form require notarization or witnesses?
Not usually. The Payment Card Industry Compliance Form itself rarely requires notarization, but state or contractual requirements may impose notary or witness rules for related legal instruments. Verify with your state notary laws and contract terms before assuming no notarization is required.
Can I use Remote Online Notarization (RON)?
Possibly. Many states permit Remote Online Notarization (RON) with identity proofing, audio-video recording, and record retention requirements, but laws differ. Check your state's notary commission rules and ensure RON sessions meet identity and evidence retention standards before relying on remote notarization.
Are eSignatures acceptable for PCI attestations?
Yes, when they meet legal tests of intent, consent, attribution, and retention. Maintain audit trails, signer authentication, and reproductions of signed records. Some acquirers may require additional attestations or formats for formal PCI submissions.
What happens if information is incorrect on the form?
Incorrect or incomplete information can trigger audit findings, require remediation, and may result in fines from card brands or acquirer penalties. Mistakes often lead to repeated requests for evidence and extended assessment timelines.
How do I correct or update a submitted form?
Update the form by creating a new version with a clear change log, obtaining re-attestation from authorized signers, attaching updated evidence, and preserving prior versions for audit history. Notify acquirers or assessors if changes affect prior attestations.

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