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Report of Stolen Credit Card

This is a credit cardholder's report of a stolen credit card. The form provided here is simply a sample of what the actual form looks like.

CARDHOLDER'S REPORT OF STOLEN CREDIT CARD

TO: __________(1)_____________

__________(2)_____________

Since receiving the ___________(3)_____________ issued under the

Number __________(4)___________, it has been stolen. The card was stolen

on or about _____(5)______, ____(6)____.

The card was stolen under the following circumstances:

(Describe Situation)

I notified ____________(7)_______________ by telephone of the theft of the card

On ________(8)____________, ____(9)____.

You are hereby authorized to take all steps necessary and to notify the appropriate authorities to avoid illegal use of the above-numbered credit card.

___________(10)_______________

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