Customer Access Request Form

Western Union Confidential Customer Access Template March 2014

Section I: Customer Information

Please complete all of the relevant information below. Failure to complete each applicable section to this request may

result in a delay to process this Customer Access Request.

Name:______________________________________ MyWU / Gold Card Number:_________________________

Postal/Street Address:__________________________________________________________________________

City:_________________________________________ State / Province:_________________________________

Postal Code:___________________________________ Country:_______________________________________

Additional Address Information (if applicable):______________________________________________________

Phone Number:_________________________________ Mobile Number:________________________________

E-Mail Address:_________________________________ Business Name (if applicable):_____________________

Section II: Previous Addresses (use additional sheets if necessary)

Please indicate any previous addresses you may have used while using Western Union services. Attach any additional previous addresses if needed. Proof of address is required if your address is not shown on your ID Document(s)

Previous Address 1

Postal/Street Address:__________________________________________________________________________

City:_________________________________________ State / Province:_________________________________

Postal Code:___________________________________ Country:_______________________________________

Additional Address Information (if applicable):______________________________________________________

Previous Address 2

Postal/Street Address:_________________________________________________________________________

City:_________________________________________ State / Province:_________________________________

Postal Code:___________________________________ Country:_______________________________________

Additional Address Information (if applicable):______________________________________________________

Customer Access Request Form

Western Union Confidential Customer Access Template March 2014

Section III: Information Requested

Please indicate what information you are requesting Western Union to release by checking the appropriate box(es)

below. Keep in mind that Western Union will only release information on file as it relates to you and only retains

information for as long as what is required by law.

Transaction History, Specify Date or Date Range:____________________________________

Account or Other Information Name of individuals you have sent or received money

from______________________________________________________________________________________________

__________________________________________________________________________________________________

Please provide any reference numbers (eg MTCN) or other information that can assist us in providing the details you are

seeking: _____________________________________________________________________________________

Section IV: ID Verification

Please attach to this form a legible copy of a government-issued identification. This document will be used to verify your

identity prior to the release of any information from Western Union. Examples of acceptable forms of identification

include, but are not limited to:

If you have used more than one ID document to make a Western Union transactions or sign up for product or service,

you should provide a copy of each ID Document used so that we locate your personal data and confirm that the personal

data relates to you.

Drivers License Passport Military I.D. Card State or National I.D. Card Permanent Resident Card

Important: We recommend you return this form and the supporting documents in a secure envelope or send through

secure electronic means. If your ID does not show your current address, additional proof of address document such as

telephone bill, utility bill or similar documentation.

Upon receipt of your request and identification verification, Western Union will provide the requested information to your postal

address on file. Please allow ten business days for us to process your request.

By signing below, you certify and assert that the information provided within this document is as accurate and factual as reasonably

possible, reflects your own identity, and that this request is being made only on your own behalf.

Signed:_________________________________________ Date:________________________________

Print Name:_____________________________________