FRAUD INVESTIGATION FORM
1. My mailing address is _____________________________________________________________
My telephone number at home is ( )____________ and at work is ( ) _____________________
2. My credit/debit card was issued by [Institution Name] and the account number is
__________________________
3. The above card was requested by me. YES NO
4. The following other person(s) were issued card(s) in their name(s) with the same account number as my Card:
_______________________________ ______________________________
_______________________________ _______________________________
5. To the best of my knowledge, my Card was: (check one of the following)
Lost …………………………………on approximately ________________
(Month/Day/Year)
Stolen …………………………………approximately _________________
(Month/Day/Year)
Never Received
In my possession at all times when the fraudulent transaction(s) occurred.
6. I learned of the fraud on approximately _____________. I reported my card lost/stolen on ______________.
Month/Day/Year Month/Day/Year
7. The transactions listed on the following page(s) of this form were (check the box next to each true statement):
Not made or authorized by me.
To the best of my knowledge not made by any person who was authorized to use my Card.
To the best of my knowledge not made by any person listed in Section 4 above.
8. I did not receive any benefit from the transactions listed on the following page(s).
9. I do do not have knowledge of the identity of the person(s) illegally using my name, account number or Card.
(If you have such knowledge, please provide this information in the section provided on the bottom of page two.)
10. I give my consent to my financial institution to release any information regarding my Card and/or Card Account to any
federal, state or local law enforcement agency so that the information can, if necessary, be used in the investigation
and/or prosecution of any person(s) who may be responsible for fraud involving my Card and/or Card Account.
Primary Secondary
Cardholder Signature _________________________________ Cardholder Signature ____________________________
List of Unauthorized Transactions
(If you are aware of additional fraud charges that are not listed, please add them below or to the backside of this page.)
Transaction Date
Transaction Amount
Merchant Name
If you have done business with the merchant(s) listed above in the past and think that this may be a billing error, please
provide any information you have in the space below. This information will allow us to properly dispute the transaction(s)
with the merchant.
If you have any knowledge of the identity of the person(s) who used your account number or Card, please provide any
information you have in the space below. If you have filed a police report, please attach a copy of the report, or provide the
name of the police station, the phone number and the case number (if you were given one).
