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 _____________, 20_____.

The card was stolen under the following circumstances:

I notified _____________________________ by telephone of the theft 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.

____________________________