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MoneyGram Historical Transaction Request

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									                                                            Historical Transaction Request                                                        p 1 of 2
                                                       International (800) 926-9400 Extension 6851



Instructions:
    •   Complete Historical Transaction Request form on the second page. A copy of your photo identification must be attached to this form.
    •   Return this form to MoneyGram International through one of the following options:
                 Fax: 1(866) 954-7475 Attention: Historical Transaction Request
                 Email: HistoricalTrnx@moneygram.com
                 Mail: MoneyGram Historical Transaction Request C322
                             PO Box 36230 Denver, Colorado 80236-6230
Please Note:
   • The fees will apply as follow:
$20.00                       $30.00                            $40.00                  $60.00        $70.00 $80.00 $80.00 $80.00 $80.00 $80.00
                                                               History from 3
History from 1 calendar yr
                            History from 2 calendar yrs        calendar yrs
or less only (example: 2002                                                            4 yrs         5yrs   6yrs    7yrs     8yrs    9yrs     10yrs
                            (example: 1999 & 2005)             (example: 1999 thru
only)
                                                               2001)
   •    Processing fees are non-refundable and are subject to change.
   •    The fee should be paid using MoneyGram express payment service. The receive code is 3941; the name of the company is MG Historical Transaction.
        The account number should be the fax number where we are going to fax this request. If there is no fax available the account number should be ones
        repeated ten times. Example “1111111111”
   •    If outside the United States please send your payment via mail using a Certified Check in US currency.
   •    Most requests are processed within 10 business days. For any further questions or concerns, contact MoneyGram ext 6851.
   •    Incomplete or illegible request may delay processing.


Reference: number: ______________________________________         Today’s Date: ________________________________________



                                               Please keep a copy of this document for your records
                                                               Historical Transaction Request                                                            p 2 of 2
                                                          International (800) 926-9400 Extension 6851



The fee was paid with
Reference Number: ____________         or mark the box if the fee was sent via mail          The time frame for my sending/receiving activity should be between:
                                                                                              Starting date: _____________ to Ending date: _____________
                                                                                                           MM / DD / YYYY                    MM / DD / YYYY
Please print clearly.
Address where the research will be sent to: ______________________________________________________________________________________________


This research will be done on:
Sender’s complete name: ____________________________________________________________________________________________________________

Sender’s Phone number: ______________________                                  Sender’s MoneyGram Reward card: _____________________________________

Sender's address is the same as the address above:

Sender’s address: ___________________________________________________________________________________________________________________

Is there any additional information about the sender that might be useful for this research such as nick names or abbreviations of names:


_________________________________________________________________________________________________________________________________

Receiver’s complete name: ____________________________________________                 Receiver’s city and state:________________________________________

Please include any additional information such as receipts, reference numbers, and previous names/addresses used at the time the transaction(s) was sent if
different from above.

_________________________________________________________________________________________________________________________________

How would you like to receive the information?
□ Fax:               _____________________________________________________________________________________________________
□ E-mail:            _____________________________________________________________________________________________________
□ Mailing Address: _____________________________________________________________________________________________________




Please send this form to MoneyGram International Inc. And please remember to attach a photocopy of valid photo identification.
                                                            Submit by Email              Print Form

								
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