STATEMENT OF FRAUD
RE: Case 2112280171C for account ending in 9328
I, Maryann Jones, hereby state that the above referenced card was (select one):
1. ____ Lost / Stolen
2. ____ Never received in the mail
3. ____ Used without my authorization, but still in my possession
I have not used the credit card account described as above for the transaction(s) listed below. I have
not
authorized anyone else to use or have possession of the credit card account described above. I did
not, and will not, receive any goods, services or other benefit as a result of the transaction(s) listed
below.
The signatures or other forms of authorization appearing on any of the sales drafts, ATM
transactions,
telephone/mail orders, or applications for the transaction(s) listed below, are and will be forgeries.
Date
Description
Amount
Disputed Amount
11/29/2021
PLENTYOFFISH
MEDIA LLC,
8883454454, TX
$87.99
$87.99
11/29/2021
CRO, ST
JULIANS, MLT
$100.00
$100.00
11/29/2021
CRO, ST
JULIANS, MLT
$100.00
$100.00
11/29/2021
CRO, ST
JULIANS, MLT
$200.00
$200.00
____ I have no knowledge of the identity or whereabouts of the person(s) responsible for the
transactions
listed above, OR:
____ I can identify the suspect as:
Name:
Phone Number:
Address:
City, State:
Please provide any additional information you may believe may be helpful in our investigation (you
may attach
additional pages, if needed):
_________________________________________________________________________________
_________________________________________________________________________________
I certify that, to the best of my knowledge and belief, all the information on this Statement is true,
correct,
complete and made in good faith. I understand that this Statement and the information it contains
may be
made available to federal, state, and/or local law enforcement agencies for such action within their
jurisdiction as they deem appropriate.
Signature: _________________________________________________
___________________
Date: