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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)______, 19__(6)_. The card was stolen under the following circumstances: (Describe Situation) I notified ____________(7)_______________ by telephone of the theft of the card on ________(8)____________, 19__(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)_______________ NOTICE The information in this document is designed to provide an outline that you can follow when formulating business or personal plans. Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before entering into any contract or agreement.