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. QSA Acknowledgement (if applicable) If a QSA was involved or assisted with this assessment, describe the role performed: Signature of QSA Date: QSA Name: QSA Company: Part 3d. ISA Acknowledgement (if applicable) If a ISA was involved or assisted with this assessment, describe the role performed: Signature of ISA Date: ISA Name: Title: Part 4. Action Plan for Non-Compliant Requirements Select the appropriate response for to PCI DSS Requirements” for each requirement. If you “Compliant answer to any of the requirements, you may be required to provide the date your Company expects to “No” be compliant 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. Compliant to PCI Remediation Date and Actions DSS Requirements PCI DSS Description of Requirement (If selected for any “NO” Requirement (Select One) Requirement) YES NO Install and maintain a firewall 1 configuration to protect cardholder data Do not use vendor-supplied 2 defaults for system passwords and other security parameters
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. QSA Acknowledgement (if applicable) If a QSA was involved or assisted with this assessment, describe the role performed: Signature of QSA Date: QSA Name: QSA Company: Part 3d. ISA Acknowledgement (if applicable) If a ISA was involved or assisted with this assessment, describe the role performed: Signature of ISA Date: ISA Name: Title: 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 be compliant 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) Remediation Date and Actions (If “NO” selected for any Requirement) YES NO 1 Install and maintain a firewall configuration to protect cardholder data 2 Do not use vendor-supplied defaults for system passwords and other security parameters