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Card: Yes No Credit Card Debit Card ATM Card Cardholder Information Home Phone ( ) City Work Phone ( ) State Zip Card Number Number of Cards Issued At the Time of the Fraudulent Transactions, my Card was: In My Possession Lost Never Received Stolen Was law enforcement notified? Yes No Date Cardholder Discovered Date Cardholder Reported Loss to Credit Date of First Fraudulent Transaction Loss Union/Processor I complete this Cardholder Dispute Form for the purpose of establishing the.

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