STATEMENT OF FRAUD
RE: Case 25010501163C for account ending in 3558
I, Jeilimar Mcconico, 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 card account described as above for the transaction(s) listed below. I have not authorized anyone else to
use or have possession of the 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
01/04/2025
REALPRIZE.COM, HAPPY
VALLEY, OR
$10.00
$10.00
01/04/2025
REALPRIZE.COM, HAPPY
VALLEY, OR
$5.00
$5.00
01/04/2025
REALPRIZE.COM, HAPPY
VALLEY, OR
$5.00
$5.00
01/04/2025
REALPRIZE.COM, HAPPY
VALLEY, OR
$5.00
$5.00
____ 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: ___________________