DECLARATION OF UNAUTHORIZED

CARD TRANSACTION(S)

Cardholder Name: / Card Number:
Address: / City: / State / Zip:
Home Phone: / ( ) – / Business Phone: / ( ) – / E-mail Address:
Checking Account Number: / Savings Account Number:

Instructions: This Declaration must be signed by the cardholder for the account listed above. If you need more room for any answer, please attach another sheet of paper to this Declaration and sign it.

I hereby declare and state as follows:

1. I am the Cardholder listed above. The following withdrawal(s) or other transaction(s) was not performed by me or by anyone whom I have authorized to use my card, nor did I receive any benefit or purchase(s) from the transaction(s). (Please list the date, amount of each disputed transaction, purchase, or charge, reason for dispute, and the merchant name.

Date / Amount / Reason for Dispute / Merchant Name

2. My card was:

LOST I discovered the card missing on (date). MISPLACED on (date).

STOLEN I discovered the card missing on (date). IN MY POSSESSION

3. I have previously reported the missing card to City National Bank.

YES on (date). NO

Please describe the loss of your card:

4. I have found or recovered my card.

YES. I found or recovered my card on (date). NO

5. I keep a record of my Personal Identification Number (PIN) with my card.

YES. Please describe where you keep the PIN:

(For example, "written on the card," or "written on a slip of paper kept with the card in my wallet.")

NO

6. If you checked a selection in Question 2, please tell us where you keep your card:

7. In the past I have loaned my card to another person to use, or I have told my PIN to another person.

YES. Please provide the name(s), address(es) and telephone number(s) of the person(s):

NO

I hereby declare, under penalty of perjury, under the laws of the State of that the foregoing is true, correct, and complete.

Executed the / day of / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / , / , at
Month / Year / City / State / Zip
(Signature) / (Please print name)
(Signature) / (Please print name)
BANK USE ONLY
Received/Reviewed by:
(Print name) / Signature
Date client notified bank: / Today’s date:
Office #: / Phone Number: / Deposit Services:

ID 03508E (Rev 01/2013) (641)