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REFERENCE NUMBER /
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RECEIVER /
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Date I Sl1Jl
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Town/City I JIltm/Jllti1i I
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h,1onday, 1\.1arch 31, 2014

Teller: Branch: TranID: Posted: HOLANI AIJ:!.PDP,T 4:"::36775240 03/31/2014

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SENDER /
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TRANSACTION

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This is our standard form client agreement upon which we intend to rely. For your own benefit and proteclion, you should read the terms and conditions which apply to your transaction on the reverse of the form caretully before signing below. Ifyou do not understand any pOintplease ask for further informalion. I acknowledge receipt of tM MoneyGramtransfer as provided above. . .
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For transactions requiring addilional information / lj';@3<~!1~

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If receiver is a US citizen, social security no / ~oL&#!;AJit!ll!ll0~, lllli'ili!.tUlll~j,/,\~i!l1 X'P3B TeJ16ep xvnH aearx Hb AHY-bIH
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MoneyGram may use the informationprovidedon this formforthe purpose of sending you further informationabout the services offeredby Monerf>ram. Ifyou wish to receivesuch information,please tickthis box./.l!1lI~0J~E~mJtt~~f\Jfl\Jf1 .B~1~~~l2i'/j'IlIll!Iili:~m#\fl\Jn~i*fI\J:ltftllm,\il.o :s1@).1jH!!1/l(tIJ Jlt!mf:;1[,g, r.J~iEJttjIL / MoneyGram 3H3 MaorraA arC8H M3A33nn""r TaHA MoneyGram-blH Y3YYJ1A3rY""4"J1r33HYYA""H DMA3rJ13H3 YY D' DISTRIBUTION: TopCopy,AgentBottom CopyCustomer / *ll}:il"IlC:
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For our complaints handting procedure, see reverse / llDIIIl~

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