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CREDIT CARD AFFIDAVIT OF FRAUD AND FORGERY FOR VISA OR MASTERCARD
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Short Description: Lost Card: Credit Card has been lost. I/We have not used the credit card account above for the purchase of the merchandise, services, ...
Content Inside: CREDIT CARD AFFIDAVIT OF FRAUD AND FORGERY FOR VISA® OR MASTERCARD® This entire form must be completed and signed by cardholder prior to their fraud claim being processed. INSTRUMENT USED: VISA MASTERCARD ACCESS NUMBER CARD NUMBER DAY TIME TELEPHONE NO. DATE THE CARD WAS CLOSED I, ________________________________________________ , residing at _____________________________________________________________________ , Cardholder Name Cardholder Address state to the best of my knowledge that the above referenced account number was (PLEASE MARK ONLY ONE APPROPRIATE SELECTION): Lost Card: Credit Card has been lost. I/We have not used the credit card account above for the purchase of the merchandise, services, cash advances, or for any other purpose since the above date Card Stolen: CredIt Card has been stolen. I/We have not used the credit card account above for the purchase of merchandise, services, cash advances, or for any other purpose since the above date Never Received in the Mail: I/We requested a credit card account from Navy Federal, but never received it at the address on file, the same address as indicated above Fraud Application: Never applied for credit card account. I/We state the account described above was applied for and issued without my knowledge and/or consent Counterfeit / Unauthorized Use of Card Number: I/We state the credit card account described above was engaged in transactions without my knowledge and/or consent I/We still had control and possession of the card(s) during the posting time of the below transaction(s) Card Account Takeover: I/We requested a credit card account from Navy Federal, however did not request for the person indicated below to be on that credit card account I/We have not used this Credit Card/Account Number for any of the transactions since the above date. I/We have not authorized anyone else, orally or in writing, or have I/we given consent or have knowledge of implied consent, to use/have possession of said CreditCard/Account Number. I/We have not, and will not, receive goods, services, or otherwise benefit directly or indirectly, from transactions made after the date shown above. I/We believe that any documentation received bearing my purported signature, or the purported signature of person(s) authorized to use my Credit Card/Account Number following the date reported above, are and will be forgeries. I/We further agree that any information relating to the unauthorized use of this account may be provided to any investigative or prosecutorial agency. I/We also agree that It may be required to provide a copy of a local police or military police report, If requested. The transaction(s) identified were not made by me or by anyone acting upon my authority or with my consent or knowledge. I have no knowledge of the identity or whereabouts of the person(s) using the Card. I can identify the suspect as: Name _____________________________________________________________________ , Address ______________________________________________ , City/State ________________________________________________ , Phone ______________________________________ , and Social Security Number _________________________________________. By signing this affidavit, I recognize that should this statement be proven false in a court of law, I could be charged with perjury. Signed _________________________________________________ Signed _________________________________________________ Primary Cardholder Secondary/Authorized User THIS AREA MUST BE COMPLETED BY THE CARDHOLDER: Please list all fraudulent charges in the area below and on the back of this form to ensure they are included with your fraud claim. List the dollar amount, the transaction date, and the payee/merchant name for each charge. AMOUNT DATE PAID PAYEE / MERCHANT $ $ $ $ NFCU 562 (6-06) Copyright © 2006 Navy Federal ADDITIONAL SPACE ON REVERSE *562*
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