Cardholder's Report Of Stolen Credit Card
Since receiving the ________________________ issued under the number____________________, it has been stolen. The card was stolen on or about ___________, 201(x).
The card was stolen under the following circumstances:
I notified ___________________________ by telephone of the theft of the card on ___________________, 201(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.