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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.