Cardholder's Report Of Lost Credit Card

TO: _____________________________________________________

Since receiving the ___________________________ issued under the number ________________________, it has been lost. I lost the card on or about ___________________, 20______.

The card was lost under the following circumstances:

I notified ______________________________ by telephone of the loss of the card on ______________________, 20______.

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.

______________________________