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Payment Card Industry Data Security Standard Form

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Payment Card Industry Data Security Standard Form

Organization Identification

Assessment Details

Assessment Type:

If SAQ, specify type:

Assessment Period Start Date:    End Date:

Scope and Environment

Cardholder Data Environment Description:

Is network segmentation implemented to isolate the cardholder data environment?  

PCI DSS Requirements Compliance Summary

For each PCI DSS requirement below, indicate current status and provide brief observations or remediation notes. Select the single status that best represents the current compliance state for each requirement.

Requirement 1 — Install and maintain network security controls

Requirement 2 — Secure system configuration

Requirement 3 — Protect stored cardholder data

Requirement 4 — Protect cardholder data in transit

Requirement 5 — Protect systems from malware

Requirement 6 — Develop and maintain secure systems and applications

Requirement 7 — Restrict access to cardholder data

Requirement 8 — Identify and authenticate access to system components

Requirement 9 — Restrict physical access to cardholder data

Requirement 10 — Log and monitor all access to system components

Requirement 11 — Regularly test security systems and processes

Requirement 12 — Maintain an information security policy

Findings, Compensating Controls & Remediation Plan

Describe any compensating controls in place that address gaps identified above. Provide specific implementation details and justification for why the compensating control meets the intended security objective.

Remediation Plan (top items)

Evidence Inventory

List evidence items that substantiate the compliance assertions (logs, policies, screenshots, scan reports). Provide a brief description and the storage location or filename.

Vulnerability Scanning and External Assessment

Approved Scanning Vendor (ASV) scan performed:

Attestation

By signing below, the Authorized Representative certifies that the information provided in this Payment Card Industry Data Security Standard Form and the attached evidence is true, accurate, and complete to the best of their knowledge. The Authorized Representative acknowledges responsibility for maintaining the security of the cardholder data environment and for timely remediation of identified deficiencies. Deliberate falsification of this attestation may result in contractual remedies, suspension or termination of card processing privileges, and other legal consequences.

The organization agrees to notify its acquiring institution and relevant stakeholders promptly of any material changes to the cardholder data environment or significant security incidents affecting cardholder data.

Authorized Representative:

By:

Date:

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What the Payment Card Industry Data Security Standard Form Is

The Payment Card Industry Data Security Standard Form documents an organization’s compliance posture against PCI DSS requirements for handling cardholder data. It is used by merchants, service providers, and acquirers to report assessment scope, control implementations, scan results, and remediation status. The form supports internal controls, third‑party assessments, and requests from payment processors or acquiring banks to verify that technical and policy controls meet PCI DSS objectives for confidentiality, integrity, and availability of cardholder data.

Why a Correct PCI DSS Form Matters

A complete and accurate PCI DSS Form demonstrates compliance to acquirers and assessors, reduces the risk of cardholder data exposure, and documents remediation timelines. Clear reporting helps avoid contractual penalties and supports investigations following incidents.

Why a Correct PCI DSS Form Matters

Who Typically Prepares or Receives This Form

Operational, security, and compliance teams prepare the form; acquirers, assessors, and internal auditors receive it.

  • Security and PCI teams within merchants and service providers responsible for evidence collection and control implementation.
  • External Qualified Security Assessors (QSAs) and internal auditors who verify technical controls and corrective actions.
  • Payment processors, acquiring banks, and risk/compliance officers who require proof of control status for merchant onboarding or ongoing monitoring.

The form centralizes compliance evidence and provides a consistent record for stakeholder review and audit purposes.

Core Sections to Include in a Professional PCI DSS Form

A professional form groups scope, technical evidence, scan and test results, control mappings, remediation status, and signatory confirmation for clarity and audit readiness.

Scope Summary

Define environments, IP ranges, system components, and third parties in scope for PCI DSS assessment, including segmentation details and excluded assets where applicable.

Control Mapping

List implemented controls mapped to PCI DSS requirement numbers, provide brief evidence references, and note any compensating controls with rationale and validation details.

Vulnerability Scans

Include external and internal scan dates, high/critical findings, scan provider name, and confirmation that required quarterly scans were performed and remediated or accepted.

Penetration Test Summary

Summarize penetration testing scope, major findings, remediation actions, and retest results where required by PCI DSS or contractual partners.

Remediation Status

Provide itemized remediation tasks, owners, target completion dates, and current status — open, in progress, mitigated, or verified closed.

Authorized Signatures

Identify approvers by name, title, and date; attest that the form is accurate and complete to the best of their knowledge under organizational policy.

Required Data Elements and Identifiers

Organization: Legal entity name
Assessment Period: Start and end dates
Scope Details: Systems and network ranges
Assessment Type: QSA or self-assessment
Issue Log: Open findings summary
Signatory: Name, title, and date

Step‑by‑Step: Completing the PCI DSS Form

Follow a consistent sequence to collect evidence, populate the form, and secure approval to streamline reviews and avoid rework.

  • 01
    Gather Evidence: Collect scans, logs, test reports, and configuration exports.
  • 02
    Map Controls: Match evidence to PCI DSS requirement numbers.
  • 03
    Record Remediations: Enter action, owner, and dates for each finding.
  • 04
    Obtain Signatures: Get authorized attestation and date of approval.

Configuring a Digital Workflow for This Form

Set up a repeatable digital workflow to reduce manual errors and maintain an audit trail for each submission and update.

Field Configuration
Document Template Lock required fields and attach evidence placeholders
Signer Order Define roles and sequential approval steps
Authentication Use email plus optional SMS or KBA for higher assurance
Audit Trail Enable timestamp, IP capture, and document history

Typical Submission and Review Flow

A structured routing model reduces processing time and ensures required stakeholders review the form before final signoff.

  • Submitter Uploads: Uploader attaches evidence and saves draft
  • Preliminary Review: Security team checks scope and findings
  • Remediation Update: Owners update statuses and upload retest evidence
  • Final Attestation: Authorized approver signs and archives

Digital Signing and eSubmission Considerations

Choose a platform that captures intent, attribution, and an immutable audit trail when submitting PCI DSS Forms electronically.

  • File Formats: PDF or PDF/A preferred for embedded evidence
  • Authentication: Email+code or stronger MFA for signers
  • Audit Data: Timestamps, IPs, and version history

Maintain exported copies and log entries for each submission to support audits and incident response without relying on third‑party retention alone.

Key Deadlines and Recurring Requirements

PCI compliance involves recurring scans and attestations; track dates carefully so assessments remain current and acceptable to acquirers.

Quarterly Scans:

External vulnerability scans are required at least quarterly and after major changes.

Annual Assessment:

Annual assessment or SAQ submission is required per merchant level and acquirer contract.

Remediation Windows:

High/critical findings should be remediated promptly and retested per policy.

Evidence Retention:

Retain scan and test evidence to support the current assessment period.

Ad hoc Requests:

Acquirers may request updated forms following incidents or contract reviews.

Consequences of Incomplete or Incorrect Forms

Contractual Fines: Acquirers may impose penalties or increased fees
Assessment Failure: Failed evidence may require full reassessment
Increased Liability: Unaddressed findings raise breach exposure
Card Network Action: Networks can levy fines or restrict processing
Reputational Harm: Publicized incidents damage customer trust
Remediation Costs: Emergency fixes and forensics increase expense

Common Preparation Mistakes to Avoid

  • Under‑scoping assets or excluding segmented systems leads to incomplete assessments and potential later findings from validators.
  • Submitting unverifiable control claims without attached evidence causes assessors to mark requirements as unmet or requires rework.
  • Using inconsistent naming for systems and configuration files complicates validation and delays acceptance by the QSA or acquirer.
  • Failing to update remediation entries and dates makes it difficult to demonstrate progress and may trigger escalated review.

Example eSignature Pricing and Feature Comparison

Platform pricing and available features affect how you manage PCI DSS Forms. Compare signNow and common competitors to match functionality to your workflow needs.

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 Yes, 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions About the PCI DSS Form

Answers below address common points of uncertainty about electronic signing, required evidence, retention, and signatory authority.


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