CARDHOLDER'S REPORT OF
STOLEN CREDIT CARD

TO: _______________________

___________________________

Since receiving the ________________________ issued under the number____________________, it has been stolen. The card was stolen on or about ___________, 200(x).

The card was stolen under the following circumstances:

(Describe Situation)

I notified ___________________________ by telephone of the theft of

the card on ___________________, 200(x).

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.

__________________________

__________________________

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