Payment Card Industry (PCI)

Data Security Standard

Attestation of Compliance for

Self-Assessment Questionnaire A
For use with PCI DSS Version 3.2.1

July 2018
Section 1: Assessment Information
Instructions for Submission
This document must be completed as a declaration of the results of the merchant’s self-assessment
with the Payment Card Industry Data Security Standard Requirements and Security Assessment
Procedures (PCI DSS). Complete all sections: The merchant is responsible for ensuring that each
section is completed by the relevant parties, as applicable. Contact acquirer (merchant bank) or the
payment brands to determine reporting and submission procedures.

Part 1. Merchant and Qualified Security Assessor Information

Part 1a. Merchant Organization Information
Company Name: AAA DBA (doing
business as):
Contact Name: Fredy Peña Title: Gerente IT
Telephone: 123123 E-mail: [email protected]
om
Business Address: asasfasfasf City: BOGOTA
State/Province: BOGOTA Country Colombia Zip: 111131
URL: asdasd
Part 1b. Qualified Security Assessor Company Information (if applicable)
Company Name:
Lead QSA Contact Name: Title:
Telephone: E-mail:
Business Address: City:
State/Province: Country Zip:
URL:
Part 2. Executive Summary
Part 2a. Type of Merchant Business (check all that apply)
X Retailer X Telecommunication Grocery and Supermarkets

Petroleum E-Commerce Mail order/telephone order (MOTO)

X Others (please specify):

What types of payment channels does your Which payment channels are covered by this
business serve? SAQ?
X Mail order/telephone order (MOTO) Mail order/telephone order (MOTO)

X E-Commerce E-Commerce

Card-present (face-to-face Card-present (face-to-face

Note: If your organization has a payment channel or process that is not covered by this SAQ, consult
your acquirer or payment brand about validation for the other channels.

PCI DSS v3.2.1 Attestation of Compliance for SAQ A, Rev 1.0 July 2018
© 2006-2018 PCI Security Standards Council, LLC. All Rights Reserved. Page 1
 Part 2b. Description of Payment Card Business
How and in what capacity does your pos ventaa presente
business store, process and/or transmit
cardholder data?

Part 2c. Locations

List types of facilities (for example, retail outlets, corporate offices, data centers, call centers, etc.)
and a summary of locations included in the PCI DSS review.

Number of facilities
Type of facility of this type Location(s) of facility (city, country)
Example: Retail outlets 3 Boston, MA, USA
tiendas 3 bogota

Part 2d. Payment Application

Does the organization use one or more Payment Applications? X Yes No
Provide the following information regarding the Payment Applications your organization uses:
Payment Application Version Application Is application PA-DSS Listing Expiry
Name Number Vendor PA-DSS Listed? date (if applicable)

Yes X No

Yes No
Yes No
Yes No
Yes No

Part 2e. Description of Environment

Provide a high-level description of the environment covered by
this assessment.
For example: jadhhhashhdahasdh
·         Connections into and out of the cardholder data environment
(CDE).
·         Critical system components within the CDE, such as POS devices,
databases, web servers, etc., and any other necessary payment
components, as applicable.

Does your business use network segmentation to affect the scope of your PCI Yes X No
DSS environment?
(Refer to “Network Segmentation” section of PCI DSS for guidance on network
segmentation)

PCI DSS v3.2.1 Attestation of Compliance for SAQ A, Rev 1.0 July 2018
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 Part 2f. Third-Party Service Providers
Does your company use a Qualified Integrator & Reseller (QIR)? Yes X No

If Yes:
Name of QIR Company:
QIR Individual Name:
Description of services provided by QIR:
Does your company share cardholder data with any third-party service Yes X No
providers (for example, Qualified Integrator & Resellers (QIR), gateways,
payment processors, payment service providers (PSP), web-hosting
companies, airline booking agents, loyalty program agents, etc.)?

If Yes:

Name of service provider: Description of services provided:

Note: Requirement 12.8 applies to all entities in this list.

Part 2g. Eligibility to Complete SAQ A

Merchant certifies eligibility to complete this shortened version of the Self-Assessment
Questionnaire because, for this payment channel:
X Merchant accepts only card-not-present (e-commerce or mail/telephone-order) transactions);

X All processing of cardholder data is entirely outsourced to PCI DSS validated third-party service
providers;
X Merchant does not electronically store, process, or transmit any cardholder data on merchant systems
or premises, but relies entirely on a third party(s) to handle all these functions;
X Merchant has confirmed that all third party(s) handling storage, processing, and/or transmission of
cardholder data are PCI DSS compliant; and
X Any cardholder data the merchant retains is on paper (for example, printed reports or receipts), and
these documents are not received electronically

X Additionally, for e-commerce channels:

All elements of the payment page(s) delivered to the consumer’s browser originate only and directly from
a PCI DSS validated third-party service provider(s).

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Section 2: Self-Assessment Questionnaire A
This Attestation of Compliance reflects the results of a self-assessment, which is documented in an
accompanying SAQ.
The assessment documented in this attestation and in the SAQ was completed on:

Have compensating controls been used to meet any requirement in the SAQ? Yes No

Were any requirements in the SAQ identified as being not applicable (N/A)? Yes No

Were any requirements in the SAQ unable to be met due to a legal constraint? Yes No

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 Section 3: Validation and Attestation Details

Part 3. PCI DSS Validation

This AOC is based on results noted in SAQ A (Section 2),dated (SAQ completion 08/03/2021).

Based on the results documented in the SAQ A noted above, the signatories identified in Parts
3b-3d, as applicable, assert(s) the following compliance status for the entity identified in Part 2 of
this document: (check one):

X Compliant: All sections of the PCI DSS SAQ are complete, all questions answered
affirmatively, resulting in an overall COMPLIANT rating; thereby (Merchant Company Name)
has demonstrated full compliance with the PCI DSS
Non-Compliant: Not all sections of the PCI DSS SAQ are complete, or not all questions are
answered affirmatively, resulting in an overall NON-COMPLIANT rating, thereby (Merchant
Company Name) has not demonstrated full compliance with the PCI DSS.
Target Date for Compliance:
An entity submitting this form with a status of Non-Compliant may be required to complete the
Action Plan in Part 4 of this document. Check with your acquirer or the payment brand(s)
before completing Part 4.
Compliant but with Legal exception: One or more requirements are marked “No” due to a
legal restriction that prevents the requirement from being met. This option requires additional
review from acquirer or payment brand.
If checked, complete the following:
Affected Requirement Details of how legal constraint prevents requirement being met

Part 3a. Acknowledgement of Status

Signatory(s) confirms:
(Check all that apply)
PCI DSS Self-Assessment Questionnaire A, Version (version of SAQ), was completed
according to the instructions therein.
All information within the above-referenced SAQ and in this attestation fairly represents the
results of my assessment in all material respects.
I have confirmed with my payment application vendor that my payment system does not store
sensitive authentication data after authorization.
I have read the PCI DSS and I recognize that I must maintain PCI DSS compliance, as
applicable to my environment, at all times.
If my environment changes, I recognize I must reassess my environment and implement any
additional PCI DSS requirements that apply.

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 Part 3a. Acknowledgement of Status (continued)
No evidence of full track data¹, CAV2, CVC2, CID, or CVV2 data², or PIN data³ storage after transaction
authorization was found on ANY system reviewed during this assessment.
ASV scans are being completed by the PCI SSC Approved Scanning Vendor (ASV Name)

Part 3b. Merchant Attestation

Signature of Merchant Executive Officer ↑ Date: 08/03/2021

Merchant Executive Officer Name: Fredy Peña Title: Gerente IT

Part 3c. Qualified Security Assessor (QSA) Acknowledgement (if applicable)

If a QSA was involved or assisted

with this assessment, describe the
role performed:

Signature of Duly Authorized Officer of QSA Company ↑ Date:

Duly Authorized Officer Name: #Error QSA Company: #Error

Part 3d. Internal Security Assessor (ISA) Involvement (if applicable)

If an ISA(s) was involved or

assisted with this assessment,
identify the ISA personnel and
describe the role performed:

1 Data encoded in the magnetic stripe or equivalent data on a chip used for authorization during a card-present
transaction. Entities may not retain full track data after transaction authorization. The only elements of track data that
may be retained are primary account number (PAN), expiration date, and cardholder name.
2 The three- or four-digit value printed by the signature panel or on the face of a payment card used to verify card-not-
present transactions.
3 Personal identification number entered by cardholder during a card-present transaction, and/or encrypted PIN block
present within the transaction message.

PCI DSS v3.2.1 Attestation of Compliance for SAQ A, Rev 1.0 July 2018
© 2006-2018 PCI Security Standards Council, LLC. All Rights Reserved. Page 6
 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 Compliant to PCI Remediation Date and
Requirement* Description of Requirement DSS Actions
Requirements (If “NO” selected for any
(Select One) Requirement)

YES NO
2 Do not use vendor-supplied
defaults for system passwords X
and other security parameters
6 Develop and maintain secure
systems and applications X

8 Identify and authenticate access

to system components X

9 Restrict physical access to

cardholder data X

12 Maintain a policy that addresses

information security for all X
personnel
* PCI DSS Requirements indicated here refer to the questions in Section 2 of the SAQ.

PCI DSS v3.2.1 Attestation of Compliance for SAQ A, Rev 1.0 July 2018
© 2006-2018 PCI Security Standards Council, LLC. All Rights Reserved. Page 7