Fillable Affidavit Of Unauthorized Use Form printable pdf download

Visa Account #

AFFIDAVIT OF UNAUTHORIZED USE

Debit Card

Credit Card

1. I affirm and state that I am:

Name:

____________________________________________________________________________________________________________________________

Mailing Address

: ___________________________________________________________________________________________________________________

City, State, Zip Code

: _______________________________________________________________________________________________________________

Phone Number: Home:

Work:

(____)___________________________________

(____)__________________________________________________________

Date of first fraudulent transaction:

Place of first fraudulent transaction

________________________

______________________________________________

I affirm that all transactions listed were not signed or authorized by me and are forgeries. I did not give, sell, or trade my VISA card(s) to anyone. I have no

knowledge that my spouse or minor children made any transaction. I wish to further state that I did not give anyone permission to use my VISA account number and /

or expiration date and or PIN number and/or Convenience checks.

I was issued________________card(s) from_________________________________________________________(Financial Institution).

At the time of these transactions, the card was in my possession:

Yes

At the time of these transactions, the card was:

Lost

Stolen

I discovered / was informed that the card was:

Lost,

Stolen,

Stolen Account Number (Mail Order Fraud or Internet fraud),

never received. The report was made to:

security/customer service,

the Financial Institution on

:_______________________

I did not receive any benefit from the transactions identified on this statement. This statement is made voluntarily for the purpose of

establishing the fact that my signature is a forgery and/or that this account was used without my knowledge and or consent.

Do you know who forged your signature(s)?

Yes

(If yes, provide details on a separate page and attach.)

have

have not

reported the lost, stolen, counterfeited card(s) to the police. If yes,

Police Department

Phone Number

Case Number

I understand this forgery and/or use without my consent is subject to investigation by local, state, and/or federal law enforcement agencies.

I may be required to comply with a court order or subpoena to give testimony. I further understand and authorize Local 804 FCU to act on my

behalf in the matter of resolving this report of fraudulent transactions

I understand that knowingly making a false sworn statement is subject to federal and or state statutes and may be punishable by fines and/or by

10.

imprisonment

I declare under penalty that the information I have provided herein is true and correct, and I will testify, declare, depose, or certify to the truth

11.

hereof before any competent tribunal, officer, or person in any case now or hereafter pending in connection with the matters contained within

this declaration

Signature of Primary Cardholder:

Signature of Secondary Cardholder:

Signature of Authorized User:

Date

PLEASE LIST ALL UNAUTHORIZED TRANSACTIONS ON THE ATTACHED FORM

After reviewing the activity on the account there is NO Fraud activity

Affidavit Of Unauthorized Use Form

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