Plastic Card Affirmation

Plastic Card Affirmation

I/We the undersigned and holder of the VISA Debit, VISA Credit or ATM Card listed below do hereby affirm that the following checked sentence applies to the disposition of said credit card.

Name

Member Number

Card Number

Card is not working.

Card (s) has been mailed to California Community Credit Union.

Card (s) has been destroyed.

Card (s) has been misplaced.

Card (s) has been stolen/lost.

Card(s) has been compromised

I wish to close my account at this time and NOT have a new card reissued.

Card (s) is in my possession, and being fully informed and aware of the penalty involved, I have refused to surrender said card(s).

If mailed, select an address

If mailed, select an address dfasdfasdfasdfs

Date card was last used

Date card was destroyed, misplaced, or stolen/lost

Explanation of how card(s) was lost or stolen

I understand if I use said card(s) after reported lost or stolen, I will be liable for the recovery fees. I realize there is a $10.00 card replacement fee.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

September 28, 2021 11:08 am PDT

Plastic Card Affirmation Uploaded by Sara Warren - [email protected] IP 69.4.146.122

November 28, 2021 10:45 pm PDT

California Community Credit Union - [email protected] added by California Community Credit Union - [email protected] as a CC'd Recipient Ip: 67.199.161.80

July 20, 2022 12:02 pm PDT

California Community Credit Union - [email protected] added by Adam McGee - [email protected] as a CC'd Recipient Ip: 50.207.9.75

November 10, 2022 1:13 pm PDT

California Community Credit Union - [email protected] added by Adam McGee - [email protected] as a CC'd Recipient Ip: 50.207.9.75

August 4, 2023 12:59 pm PDT

California Community Credit Union - [email protected] added by Sara Warren - [email protected] as a CC'd Recipient Ip: 69.4.146.122