Sorry to say we don't have a model form filled out for you.
In
terms of review we're not able to sign of on it ( there's a clear
conflict of interest for one thing) but if it would help we can put you
in touch with our QSA.
One thing you'll
want is our AOC (attestation of Compliance). The latest version of this
can always be found in the Manage Account -> Downloads section of our
website. Please do give me a call if you'd like a hand finding it.