Is an electronic signature legally valid on this form?

Yes. Under the federal ESIGN Act (15 U.S.C. §7001) and UETA in most states, electronic signatures are legally enforceable when the signature demonstrates intent, consent, attribution, and records can be reproduced.

Do I need a QSA or can I use an SAQ?

Use a Self‑Assessment Questionnaire (SAQ) for applicable merchant levels when allowed by card brands; larger merchants or complex environments typically require a QSA‑prepared Report on Compliance for full validation.

What happens if scope is incomplete?

Incomplete scope can lead to audit findings, expanded remediation obligations, and potential card‑brand fines; ensure network segmentation and third‑party boundaries are documented and validated.

Can supporting evidence be attached electronically?

Yes. Attach ASV reports, scan outputs, and vendor AOCs to the form so auditors can verify answers without separate requests; preserve original file metadata and an audit trail.

Who should sign the attestation?

An authorized company officer with responsibility for security controls—commonly the CISO, VP IT, or a designated compliance officer—should sign and date the attestation.

How long should I keep signed attestations and scans?

Retain signed attestations and supporting evidence for at least three years post‑assessment; extend retention per contractual, industry, or regulatory requirements.

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PCI DSS Compliance Form

PCI DSS Compliance Form

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PCI DSS Compliance Form

Parties and Recitals

This Agreement is entered into between Merchant Name: and Compliance Assessor Name: (collectively, the Parties).

WHEREAS, Merchant operates cardholder data environments and requires evaluation, testing, and/or reporting in accordance with the Payment Card Industry Data Security Standard (PCI DSS); and

WHEREAS, Assessor is qualified to perform PCI DSS assessments, attestations, and remediation advisory services and will perform the services set forth herein under the terms of this Agreement; and

WHEREAS, the Parties agree to document the scope, deliverables, payment, and legal terms governing the assessment and any related remediation activity.

Administrative Details

Merchant Business Address Primary Contact Name Contact Email Contact Phone

Scope of Work

Assessment Scope: The assessment shall cover the cardholder data environment, related systems, networks, and processes identified by Merchant. SAQ/Report Type: . Network Segmentation Implemented:

Detailed Scope and Tasks

Assessment Period Start: Assessment Period End:

Payment Terms

Fee: Merchant agrees to pay Assessor a total fee of $ for the services described herein. Payment Schedule:

Late Payment

Any payment not received within days of invoice due date will incur a late fee of per month on the outstanding balance, and the Assessor may suspend services until payment is made.

Remediation, Evidence and Reporting

Remediation Plan Summary

Remediation Completion Target Date: Evidence Submitted: Check if evidence has been provided to Assessor

Evidence Description

Term and Termination

Term Commencement Date: Term Expiration Date:

Either Party may terminate this Agreement for convenience upon written notice to the other Party delivered at least days prior to the effective date of termination. Either Party may terminate immediately for material breach that remains uncured for a period of days after written notice of the breach.

Confidentiality

Each Party agrees to maintain the confidentiality of the other Party's Confidential Information. Confidential Information includes, without limitation, cardholder data, scan reports, assessment findings, internal network diagrams, remediation plans, and evidence files. The receiving Party shall use the same degree of care to protect Confidential Information as it uses for its own confidential information, but in no event less than a reasonable standard of care.

Notwithstanding the foregoing, Assessor may disclose confidential assessment results to card brands or acquiring banks when required by contract or regulation; Assessor shall provide Merchant with prior notice of such compelled disclosures where lawful to do so.

Attestation of Compliance

Assessor attests that the assessment was performed in accordance with applicable PCI DSS requirements and that the findings and evidence recorded are true and accurate to the best of Assessor's knowledge. Attestation Status:

Compliant – Merchant meets PCI DSS requirements as of assessment date
Non-Compliant – Material deficiencies identified; remediation required
Partial – Some requirements not fully assessed or require follow-up

Assessor Notes on Attestation

Representations; Limitations

Merchant represents that it has disclosed all material details concerning its cardholder data environment and that configuration, network, or application changes that occur after the assessment may affect compliance status. Assessor's services do not guarantee immunity from data compromise; Assessor's liability shall be limited to direct damages not to exceed the total fees paid under this Agreement.

Governing Law and Entire Agreement

This Agreement shall be governed by and construed in accordance with the laws of the state specified by Merchant: without regard to its conflicts of law principles. This Agreement, together with any attachments or exhibits executed by the Parties, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior oral or written representations, communications, and prior agreements.

Signatures

Merchant:

By:

Date:

Compliance Assessor:

By:

Date:

What the PCI DSS Compliance Form Is and when organizations use it

A PCI DSS Compliance Form documents an entity's controls and attestations related to the Payment Card Industry Data Security Standard (PCI DSS). It can include a Self‑Assessment Questionnaire (SAQ), Attestation of Compliance (AOC), or evidence summary prepared for card brands, acquiring banks, or internal audit. The form records scope, compensating controls, responsible parties, and dates of assessments. Organizations use the form to demonstrate compliance during merchant onboarding, annual reviews, vulnerability assessments, or after material environment changes that affect cardholder data.

Why a clear PCI DSS Compliance Form matters for risk and audit readiness

A concise, accurate form establishes what was assessed, who is responsible, and when controls were validated, reducing uncertainty during audits and vendor reviews.

Primary roles that prepare or sign a PCI DSS Compliance Form

Teams and individuals typically involved in preparing or approving the form vary by organization size and structure.

Security/compliance teams responsible for control mapping, gap remediation, and audit responses.
IT/operations staff who maintain system inventories, segmentation, and vulnerability scans.
Finance or merchant services contacts coordinating with acquirers and card brands for attestations.

Final signers should be authorized representatives who can attest to the accuracy of technical and administrative controls.

Stepwise process to fill out the PCI DSS Compliance Form

A clear sequence reduces omissions and ensures the form aligns with technical evidence and scan outputs.

01

Collect scope data: Inventory systems and third parties in scope.
02

Run scans and tests: Obtain latest ASV scans and internal test results.
03

Complete SAQ/AOC fields: Populate answers, references, and compensating control notes.
04

Obtain authorized signature: Have an authorized officer sign and date the form.

Where the completed form typically goes after signing

Routing depends on why the form was prepared—onboarding, annual attestation, or incident response.

Acquiring Bank: Submit to your acquirer for merchant onboarding or compliance requests.
Card Brands: Provide AOC or SAQ results when requested by Visa, Mastercard, or other brands.
Internal Audit: Retain copies with audit evidence and change logs for internal reviewers.
Third‑party Providers: Share scoped third‑party attestations (processors, gateways) as supporting evidence.

Configuring an electronic workflow for PCI DSS attestations

Digitally routing the form reduces turnaround time and preserves an audit trail if configured correctly.

Field	Configuration
Signature Authentication	Email link or SMS OTP; use stronger auth for executive signers.
Evidence Attachments	Embed ASV reports, scan screenshots, and third‑party AOCs as required.
Role Order	Set signer sequence: preparer → security approver → authorized officer.
Retention Policy	Auto‑archive signed records to secure storage for the retention period.

Technical considerations for eSubmission and auditability

Choose a platform that preserves tamper‑evident copies, detailed audit trails, and secure storage.

Document formats: PDF/A or DOCX supported
Authentication methods: Email, SMS, or advanced MFA
Integrations: CRM and cloud storage supported

Ensure the chosen solution complies with legal e‑signature frameworks and retains metadata needed for audits.

Typical eSignature vendor comparison for PCI DSS attestations

Vendor choice affects cost, authentication options, and whether you can attach evidence and maintain audit trails for PCI reviews.

	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 free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Essential elements to include in a professional PCI DSS Compliance Form

A well‑structured form improves clarity and supports faster validation by acquirers, assessors, and internal auditors.

Scope Statement

Clear definition of systems, networks, and third parties in scope, including segmentation boundaries and excluded components to avoid scope drift during review.

Control Mapping

Cross‑reference each PCI DSS requirement to implemented controls, evidence artifacts, and owners to simplify auditor verification and reduce follow‑up requests.

Evidence Index

Indexed attachments such as ASV scan reports, penetration test summaries, and third‑party AOCs with filenames and dates for reproducible review.

Compensating Controls

Describe compensating controls where full technical compliance is impractical, including justification, risk assessment, and timeframe for remediation.

Assessment Summary

Result overview: compliant, not compliant, or partial; include high‑risk findings, remediation status, and next assessment date.

Authorized Attestation

Name, title, signature, and date of the authorized officer attesting to the accuracy of the form and the period covered by the assessment.

Security and compliance facts to document on the form

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

PCI DSS: Document PCI DSS scope and SAQ type

Audit Trail: Timestamped action logs and IP addresses

Access Controls: Role‑based access and MFA

Third Parties: Processors with their AOC references

Retention: Preserve signed records and metadata

Consequences and risks from incomplete or inaccurate PCI DSS forms

Card Network Fines: Card brands may levy fines for non‑compliance

Higher Fees: Increased acquiring fees or termination risk

Breach Liability: Civil and contractual exposure after incidents

Remediation Costs: Extensive forensics and mitigation expenses

Reputational Harm: Customer trust and partner access affected

Audit Findings: Repeat findings increase oversight requirements

Key timing and reporting expectations for PCI DSS attestations

Timely assessments and scans are mandatory to maintain valid attestations and to meet acquirer or card brand requirements.

Annual Attestation:

SAQ or QSA report completed once per compliance year

Quarterly Scanning:

ASV scans required at least quarterly with passing results

After Significant Change:

Reassess scope when architecture or providers change

Incident Reporting:

Notify acquirer/card brand per contract timelines

Remediation Timelines:

Document deadlines for high‑risk finding closures

Frequently asked questions about completing and submitting a PCI DSS Compliance Form

Answers focus on common completion, submission, and legal validity issues encountered by merchants and service providers.

Need help? Contact support

Is an electronic signature legally valid on this form?
Yes. Under the federal ESIGN Act (15 U.S.C. §7001) and UETA in most states, electronic signatures are legally enforceable when the signature demonstrates intent, consent, attribution, and records can be reproduced.
Do I need a QSA or can I use an SAQ?
Use a Self‑Assessment Questionnaire (SAQ) for applicable merchant levels when allowed by card brands; larger merchants or complex environments typically require a QSA‑prepared Report on Compliance for full validation.
What happens if scope is incomplete?
Incomplete scope can lead to audit findings, expanded remediation obligations, and potential card‑brand fines; ensure network segmentation and third‑party boundaries are documented and validated.
Can supporting evidence be attached electronically?
Yes. Attach ASV reports, scan outputs, and vendor AOCs to the form so auditors can verify answers without separate requests; preserve original file metadata and an audit trail.
Who should sign the attestation?
An authorized company officer with responsibility for security controls—commonly the CISO, VP IT, or a designated compliance officer—should sign and date the attestation.
How long should I keep signed attestations and scans?
Retain signed attestations and supporting evidence for at least three years post‑assessment; extend retention per contractual, industry, or regulatory requirements.

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