__________(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)______________