Re: Wells Fargo WellsOne Commercial Card
Account Number:
I, , have reported that my above numbered card or account (please check and complete applicable section):
_____ With an expiration date of __________________ was not received by me.
_____ Was discovered missing on ________________________ .
_____ Was stolen on ______________, at ________________.
I have notified the police, who took report #_______________.
_____ May have been used without my authorization, though valid card was in my possession at all times.
_____ Additional information enclosed on separate sheet.
I last used the said card on , 20 in the city of .
Any duplicate of this card has been destroyed.
The transaction(s) listed below or on the attached sheet and/or transaction made after the date of the last usage were not made by me or by a person acting with my authorization. I received no benefit whatsoever from such use. I further authorize you to accept my telephone verification of any subsequent transaction(s).
TRANSACTION DESCRIPTION TRANSACTION DATE AMOUNT
I declare under penalty of perjury that the foregoing is true and correct, and I will testify, declare, depose or certify to the truth hereof before any competent tribunal, officer, or person in any case now or hereafter pending in connection with the matters contained within this declaration.
Executed at (City/County and State) Date
Signature of Cardholder
Signature of Other Authorized User Signature Of Other Authorized User
STATE OF ARIZONA }
}ss.
County of Yuma }
SUBSCRIBED AND SWORN before me this_______ day of__________, 20___ by
.
Notary Public
My commission expires: .
(Res. 2008-011, passed 2-19-2008)