Citi® Prepaid Services

Citi Prepaid Declaration of Unauthorized/Fraudulent Use

**IMPORTANT ** please read

Please contact Citi Prepaid to IMMEDIATELY REISSUE your account. Reissuing your account prevents additional fraud charges from occurring (as the unauthorized party cannot access your new account number). This Declaration of Fraud CANNOT be processed until account has been reissued.

* I, / , the undersigned, do hereby state and declare as follows
Please indicate:
*Name (as it appears on the card) :
*Address (street, city, state + zip code) :
*Phone number(s) : / email address: ______
1. / This Declaration concerns Citi Prepaid T-Mobile Card # ______
(Account with fraudulent charges)
*2. I have indicated that the below transactions are fraudulent: (or attached transaction history)
DATE / MERCHANT / AMOUNT

IMPORTANT: Fraudulent charges over 120 days cannot be processed.

** If you have check fraud, please indicate date of check, amount of check and check number in chart above. Customer Service can provide this information to you. **

3. Neither I, nor anyone authorized by me, or anyone with my knowledge or consent, received or expects to receive any benefits or value as a result of this transaction(s).

*4. My card was: (circle one)
a. LOST (or) *STOLEN: Date: / Location:
* If Stolen: Police report filed? / YES (or) NO
Case # / City
Detective / Phone Number
  1. NEVER RECEIVED
  1. IN MY POSSESSION at the time of the unauthorized or fraudulent use.

*5. I have reason to believe the following individual(s) utilized the debit card(s) described above orhad access to my account number without my authorization:

Name(s)

Address(s) + City, State, Zip

Citi® Prepaid Services

*6. Reason; briefly describe how you think this person accessed your account:

*7. The signatures set forth below are the signatures ofall authorized userson this account:

PRINT NAME / SIGNATURE
______
______

*8. I understand that Risk Management investigates alleged fraudulent or unauthorized debit card

usage and may refer the same to the appropriate law enforcement agency. I agree to cooperate in any prosecution of individuals charged with fraudulent or unauthorized debit card usage.

______

PRIMARY CARDHOLDER SIGNATURE

AFTER YOU HAVE COMPLETED THIS FORM:

*1) PleaseMAILback the signed Declaration to the address below:

Citi Prepaid

PO Box 6135

Sioux Falls, SD 57117-6135

OR Fax to: 1-855-566-7626

(Most fraud investigations are completed within 45 days from receipt; however, it may take up to 90 days to finalize depending on the nature of the disputed charges.)

2) Please CHECK YOUR ACCOUNT 45 days after you have mailed this Declaration to see if your account has been credited for fraudulent charges. If we have questions, we will contact you directly.

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FOR INTERNAL USE ONLY

  • card status at time of transaction:LOSTSTOLENCOUNTERFEIT
  • date fraud activity was reported to Visa/MasterCard: ______
  • Date the account number was listed on the exception file:______