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Declaration of Fraud

Fraud declaration

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damiensdaddy
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27 views2 pages

Declaration of Fraud

Fraud declaration

Uploaded by

damiensdaddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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®

DECLARATION OF FRAUD

Account(s) Ending In: ________

I, _______________________________, hereby declare that American Express


(Your Name)

Card and/or number _________-____________-_____________

was fraudulently used, that I have examined the following transactions and further state that the transactions were
not incurred by me nor any person with my authority, either expressed, implied, or apparent, and that I have not
received and will not receive, directly or indirectly any benefit there from.

DATE U.S. AMOUNT INTL. AMOUNT ESTABLISHMENT NAME


________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________
________ __________________ _________________ ___________________________

If you require additional space to complete your statement, please attach additional page(s).

I also certify that the following is true and correct:

Please describe the circumstances surrounding your claim. (If you require additional space to complete your
statement, please attach additional page(s).)

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

1. Are you in possession of the above listed American Express Card?


Yes _____ No _____ If not in possession, was the Card:
Lost _____ Stolen _____ Never Received ___ Other _________ (Specify)
If Stolen: Police Report Filed?: Yes ___ No ___
City _____________________ Precinct ____________ Case # _________
2. Did you, or have you ever allowed the American Express Card to be used by someone other than yourself?
Yes_____ No______

If you answered yes, please list the names(s) of individuals you have allowed to use your American Express
Account.

________________________________________________________________________________

3. Is your claim related to an ATM withdrawal? Yes____ No ____

If you answered yes, please advise how the PIN could have been obtained?

________________________________________________________________________________

4. Do you have knowledge as to who made the fraudulent charge(s) listed above?
Yes ___ No ___

If answered yes, for what reason do you suspect that this individual made the fraudulent charge(s) to your
account?
___________________________________________________________________________________
___________________________________________________________________________________

5. Suspect description: Full Name ________________________________________________________


Relationship to you (if any) ___________________________________________________________
Address _______________________________ City ________________ State _____ Zip__________
Phone ________________________ Age/Date of Birth ____________________ Gender M/F ______
Social Security No. _______________________ Place of Employment ________________________
Physical Description: height, weight, eye/hair color, glasses, scars, etc.
___________________________________________________________________________________
___________________________________________________________________________________

6. I may be reached at the following phone number during work hours


Phone ( ) ______-____________

7. This Declaration will certify the truth of all the foregoing before any competent tribunal, officer, or
person in any case now pending or that may be hereafter instituted in connection with the matter
contained in this Declaration.

8. I agree to cooperate in the prosecution of any individuals charged with the fraudulent activity on the
above listed account.

9. I declare that above given information is true and correct to my knowledge. I understand that I can be held
liable for all charges incurred if a dispute raised by me is found invalid and may incur criminal and/or civil
liability if I am found by a court of competent jurisdiction to have knowingly reported a false claim.

____________________ ____________________________________
Date Card Member Signature

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