TO: __________(1)_____________

__________(2)_____________

Since receiving the ___________(3)_____________ issued under the number __________(4)___________, it has been lost. I lost the card on or about _______(5)__________, 19__(6)_.

The card was lost under the following circumstances:

(Describe Situation)

I notified ___________(7)________________ by telephone of the loss 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.