Certegy inc

AFFIDAVIT OF FRAUD
State of _____________________________________ County of ______________________________________ I, _____________________________________________________________ , being duly sworn, deposes and says My mailing address is __________________________________________________________________ My telephone number at home is (___) _______________and at work is (___)_____________________ My Visa/MasterCard credit/debit card (‘Card’) was issued by ___________________________________ and the account number is _______________________________________________________________ The following other persons were issued cards in their names with the same account number as my Card _____________________________________________________________________________________ _____________________________________________________________________________________ 5. To the best of my knowledge, my Card was: (check one of the following)
Lost…………………….approximately ______________________ Stolen……………….approximately ______________________ In my possession at all times when the fraudulent transactions occurred I learned of the fraud on approximately ______________. I reported my Card lost/stolen on ____________. 7. The Transactions listed on the following page(s) of this form were (check the box next to each true statement)
not made, nor 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 I did not receive any benefit from the Transactions listed on the following page(s). don’t 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.) 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. PLEASE SIGN BELOW IN FRONT OF A NOTARY PUBLIC AND PROVIDE ADDITIONAL SIGNATURE For your protection California law requires the following to appear on the form. Any person who knowingly prevents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Cardholder Signature: ___________________________ Cardholder Signature: ___________________________ Subscribed and sworn to before me on this ______ day of _______________, 20__________ _________________________________________________(seal) Notary Public
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List of Unauthorized Transactions
(If you are aware of the additional fraud charges that are not listed, please add them below or to the back side of this page)
Trandate
Merchant Description
Please provide five (5) examples of your signature below: ______________________________________________ ____________________________________________ ______________________________________________ ____________________________________________ ______________________________________________ ____________________________________________ ______________________________________________ ____________________________________________ ______________________________________________ ____________________________________________ 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 who used you 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). ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.icbabancard.org/files/Bancard/PDFs/Affidavit.pdf