IDT Payment Services, Inc.
520 Broad Street
Newark, NJ 07102 USA
[Link]
Complete and fax with a copy of required documentation to 800-949-1608
IDT BSA COMPLIANCE FORM 973-438-1145. Or email at compliance@[Link].
Call 800-618-3172 if you have questions.
Direct to Consumers
DATE ___________________ AMOUNT $ _______________ TRANSACTION #__________________________
Beneficiary Information:
Name: ____________________________________________________ Address: ____________________________________
City:_________________________ State:_______ Zip:__________ Country: _____________________________________
Sender Information:
Name:_____________________________________________________ Address: _____________________________________
City: ________________________ State: ________ Zip: ________ _____________________________________
Sender DOB (Month / Day / Year):_______________________________ ____________________________________
Sender Type of ID:
Driver’s License ID No. _________________________________________
State Issued ID
Alien Card Issued By: ______________________________________
Military ID
Passport Expiration: _____________________________________
Other (describe)
Social Security or ITIN:___________________________
Sender Specific Occupation: ____________________________________________________________
Sender Relationship with Beneficiary: ___________________________________________________
Reason and/or purpose of the transaction: ________________________________________________
ALL AGENTS: ALSO COMPLETE BELOW FOR TRANSACTIONS OF $5,000 OR MORE (INCLUDING FEE).
EMPLOYER NAME: EMPLOYER PHONE:
EMPLOYER ADDRESS:
OCCUPATION AND
INDUSTRY
SENDER’S SOURCE OF
FUNDS:
EVIDENCE OF SOURCE
OF FUNDS:
○ Tax Returns ○ Pay Check ○ Other: Describe
○ Bank Statement together ○ Loan Documents or
with withdrawal receipt Settlement of Insurance or
mortgage refinance
SENDER SIGNATURES
SENDER SIGNATURE: ____________________________ DATE: ____________________
By signing this Form, you as the sender hereby represent and warrant to IDT Payment Services, Inc. (“IDT”) that: (1) the information and
documentation provided by you in or with this Form is true, current and complete in all respects; (2) the funds used by you to pay for the transaction
are from legitimate sources; and (3) the transaction and funds will not promote or involve any illegal activity, including fraud or money laundering.
Furthermore, you hereby authorize IDT, directly or indirectly through third parties, to make any inquiries we consider necessary to validate the
information that you provide to us, which may include verifying your information against third party databases or through other sources.
Version 02/12/2017