California Adventist Federal Credit Union AFFIDAVIT OF FRAUD 1441 E Chevy Chase Drive Glendale, Ca Ph: , Fax:
|
|
- Juniper Wilkerson
- 5 years ago
- Views:
Transcription
1 California Adventist Federal Credit Union AFFIDAVIT OF FRAUD 1441 E Chevy Chase Drive Glendale, Ca Ph: , Fax: State of County of I,, being duly sworn, deposes and says: 1. My mailing address is My Phone Number at home is ( ) - and at work is ( ) My Visa/Master credit card/debit card ( Card ) was issued by CAFCU and the Account number is _. 3. The above card was requested by me Yes _No 4. The following other persons were issued cards in their names with the same account number as my card: 5. To the best of my knowledge, my card was: (check one of the following): Lost Approximately mo/day/yr Stolen Approximately mo/day/yr Never Received. In my possession at all times when the fraudulent transaction occurred. 6. I learned of the fraud on approximately mm/dd/yy. I reported my Card lost/stolen on mm/dd/yy. 7. The Transactions listed on the following page(s) of this form were: (check the box next to each true statement). Not made, nor authorized, by me. to the best of my knowledge, not made by any person who was authorized to use my Card. to the best of my knowledge, not made by any person listed in Section 4 above.
2 8. I did not have received any benefits from the transactions listed on the following page(s). 9. I do don t have knowledge of the identity of the person(s) illegally using my name, account number, or Card. (If you have such knowledge, please provide this information in the section provided on the bottom of page two.) 10. I give consent to my financial institution to release any information regarding my Card and/or Card Account to any federal, state, or local law enforcement agency so that the information can, if necessary, be used in the investigation and/or prosecution of any person(s) who may be responsible for fraud involving my Card and/or Card Account. PLEASE SIGN BELOW IN FRONT OF A NOTARY PUBLIC AND PROVIDE ADDITIONAL SIGNATURE SAMPLES ON THE NEXT PAGE For your protection, California law requires the following to appear on form. Any person who knowingly presents a false or fraudulent claim for the payment of loss is guilty of a crime and may be subject to fines and confinement in state prison. Primary Cardholder Signature: Secondary Cardholder Signature: Subscribed and sworn to before me on this of,20. Day (seal) Notary Public _ My Commission Expires
3 List of Unauthorized Transactions: (If you are aware of additional fraud charges that are not noted, please notify institution as soon as possible.) Transaction date: Transaction Amt: Merchant Description Please provide five (5) examples of your signature below: Primary Cardholder Signature Secondary Cardholder Signature If you have done business with the merchants(s) listed above, in the past and think that this may be a billing error, please provide any information you have in the space below. This information will allow us to properly dispute the transaction(s) with the merchant. If you have any knowledge of the identity of the person who used your account number or Card, please provide any information you have in the space below. If you have filed a police
4 report, please attach an original copy of the Police report filed. Also, provide the name of the police station, the phone number and the case number, (if you were give one).
5 CALIFORNIA ADVENTIST FEDERAL CREDIT UNION 1441 E. Chevy Chase Drive, Glendale, Ca (818) / (818) FAX CHECKING ACCOUNT/SHARE DRAFT DISPUTE FORM This Dispute Form is for the purpose of establishing the fraudulent use of my account. I did not give any permission of its use. I have no knowledge that my spouse or my children made any transaction(s) on or after the date of the first fraudulent transaction indicated below. Name: home #: ( ) work #: ( ) Mailing Address Street City State ZIP The following is the list of transaction(s) in dispute: a. Date: Unauthorized user: Amount $ b. Date: Unauthorized user: Amount $: c. Date: Unauthorized user: Amount $: I have examined all of the unauthorized transaction(s) and in each instance I did not originate the transaction nor authorized it. Further, I did not receive any of the proceeds of any such item(s) on the above total. I swear that this Dispute Form is true and understand that making a false sworn statement is subject to federal and/or state statues. STATE OF COUNTY OF Subscribe and sworn to before me this Day of 200 Member Signature Date (Notary Public)
Debit and ATM/POS Card Fraud Checklist
Debit and ATM/POS Card Fraud Checklist Employee name: Member Name: Completed: Add Contact to the account and Route to VISA Member email address Printout member statement(s) (Review transactions) Police
More informationE-Teller In Branch Paper Statement Statement Visa Fraud Prevention Phone MSR. Other:
Account Number: Last 4 Digits of Card: Card Fraud Questionnaire How did you discover the fraudulent transactions on your account? (Circle One) E-Teller In Branch Paper Statement Email Statement Visa Fraud
More informationAFFIDAVIT OF UNAUTHORIZED CHECK / DEBIT WITHDRAWAL(S)
AFFIDAVIT OF UNAUTHORIZED CHECK / DEBIT WITHDRAWAL(S) IMPORTANT: The person alleging an unauthorized withdrawal must complete this form in longhand, using black ink only. I,, being first duly sworn, hereby
More informationDebit/ATM Card Fraudulent Transaction Form
Debit/ATM Card Fraudulent Transaction Form By signing this form you are affirming that you have examined all of the unauthorized transactions and in each instance you or any other authorized user did not:
More informationDEBIT CARD FRAUD CLAIM PACKET
DEBIT CARD FRAUD CLAIM PACKET Dear Member, Fraud is an unfortunate event to which we are all susceptible. United Community Credit Union is here to assist you in the process of recovering your funds. In
More informationBusiness Point of Sale/ Purchase Error Resolution Form
Page 1 of 5 Please Read Before Proceeding 1. This form must be completed by the person whose name appears on the ATM or debit card. 2. Complete Pages 1 and 5 if you are reporting unauthorized or fraudulent
More informationSECURITY AFFIDAVIT. (1) My full legal name (First) (Middle) (Last) (Jr.,Sr.,III) (First) (Middle) (Last) (Jr., Sr., III)
Your Correct Information Name: «Rep_Name» Phone Number: «Rep_Phone_Ext_Str» Case #: «Case_ID» SECURITY AFFIDAVIT (1) My full legal name (First) (Middle) (Last) (Jr.,Sr.,III) (2) Other names I have used:
More informationSeattle Metropolitan Credit Union Error Resolution Form
Seattle Metropolitan Credit Union Error Resolution Form Name: Account #: ATM or Debit Card Number: Phone: Email: Provisional credit will be posted to your account within 5 business days upon receipt of
More informationPlease contact if you have additional questions regarding your claim.
Upon receipt of this completed packet, Kinecta Federal Credit Union will research your claim. The Credit Union will resolve your claim within 10 business days or will contact you directly for additional
More informationFIS Dispute Resolution Center Dispute/Fraud Cover Sheet. Fax: Mail: PO BOX Tampa, FL From: (Institution Name): Phone:
FIS Attention: Chargeback Services (Chargeback Customer Service Inquiries) : 1.800.600.5249 Revised: 10/18/2013 Fax: 1.800.253.1220 Mail: PO BOX 30495 Tampa, FL 33630 3495 From: (Institution Name): Phone:
More informationLost Instrument Bond Application PRINCIPAL INFORMATION
801 S Figueroa Street, Suite 700 Los Angeles, CA 90017 USA Tel: 310-649-0990 Lost Instrument Bond Application A PRINCIPAL INFORMATION FIRST NAME/ MIDDLE NAME/ LAST NAME (AS IT SHOULD APPEAR ON THE BOND)
More informationSTATEMENT OF LOSS. Please complete all forms and return.
STATEMENT OF LOSS Please complete all forms and return. Name: MiniCo claim #: Address: Customer policy #: City/ST/ZIP: Policy amt: Home phone #: Cell #: DOB: Marital status: Social Security #: Employer:
More informationCITY OF BOYNTON BEACH POLICE OFFICERS PENSION FUND
BUY-BACK PACKET The attached forms must be filled-out completely. If any of these forms are received incomplete or not fill-out completely, then the forms will be returned to the member and will be deemed
More informationID Theft Insurance HOW TO FILE A CLAIM
ID Theft Insurance HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): The completed claim form Copy of all correspondence, police reports,
More informationIdentity Theft Packet
Identity Theft Packet Teller number Date received Account number Revised: 12.12.17 Identity Theft Packet Page 1 Valued Member: Thank you for contacting Educational System Federal Credit Union regarding
More informationIDENTITY THEFT PACKET
IDENTITY THEFT PACKET Teller # Date Received: Account Number: IDENTITY THEFT PACKET 1 Valued Member: Thank you for contacting Educational System Federal Credit Union regarding the suspected theft of your
More informationExcess Baggage Protection Baggage Delay
CHUBB Excess Baggage Protection Baggage Delay HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents: Copy of payment or denial from common carrier (e.g.,
More informationCITY OF ACWORTH 4415 Senator Russell Avenue Acworth, GA Fax Alcoholic Beverage License Renewal Application
INSTRUCTIONS: PLEASE PRINT OR TYPE Type of License: (Check all that apply) LIQUOR: BEER: WINE: NEW NEW NEW RENEWAL RENEWAL RENEWAL TRANSFER TRANSFER TRANSFER NAME CHANGE NAME CHANGE NAME CHANGE MANUFACTURER
More informationLoss/Collision Damage Waiver HOW TO FILE A CLAIM
Loss/Collision Damage Waiver HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): Copy of rental car agreement Copy of police report
More informationPaul Hastings LLP Defined Contribution Retirement Plan (401k) Beneficiary Designation Form
Paul Hastings LLP Defined Contribution Retirement Plan (401k) Beneficiary Designation Form Print Name: Job Title: Social Security Number: (Optional) I understand that benefits are paid out in a lump sum.
More informationMay be furnished by any three (3) persons who have known the applicant (agent) for at least three (3) years. Include name, address & phone number.
Two Original Applications Personal History Form Lease or Valid Document Photographs Corporate Papers Letters of Reference Financial Investments Please write legibly in BLACK ink or type information. Answer
More informationID Theft Affidavit. Victim Information
(3) My date of birth is (6) My current address is Name Phone number Page 1 ID Theft Affidavit Victim Information (1) My full legal name is (First) (Middle) (Last) (Jr., Sr., Ill) (2) (If different from
More informationIN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION., ) ) Petitioner, ) ) Civil Action File No. and ) ), ) ) Respondent.
IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION, Petitioner, Civil Action File No. and, Respondent. ANSWERS TO INTERROGATORIES No later than thirty (30 days from the filing of the
More informationCLAIMANT OPTION REQUEST Nonqualified Annuity Non-Spouse Beneficiary
Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 Mailing : Symetra Life Insurance Company PO Box 3882 Seattle, WA 98124-3882 Phone 1-800-796-3872 TTY/TDD 1-800-833-6388
More informationANNUITY CLAIMANT STATEMENT
ANNUITY CLAIMANT STATEMENT Section 1. GENERAL INSTRUCTIONS Please sign and return the completed form along with an original Certified Death Certificate for the deceased and the original contract or certificate
More informationDispute Resolution Center
FIS Attention: Chargeback Services (Chargeback Customer Service Inquiries) : 1.800.600.5249 Fax: 1.800.253.1220 Mail: P.O. BOX 30495 Tampa, FL 33630 3495 Revised: 10/18/2013 From: (Institution Name): Phone:
More informationHousing Contract Administration. August 2018
Housing Contract Administration Income Calculation Policies and Procedures August 2018 SELF-EMPLOYMENT INCOME & INCOME FROM A BUSINESS Kentucky Housing Corporation 1231 Louisville Road Frankfort, KY 40601
More information*** All renewal applications must be filed by March 1, 2019 ***
REAL ESTATE AND MOBILE HOME TAX RELIEF APPLICATION Office of the Tel.: (804) 652-2161 Fax: (804) 829-6228 2019 *** All renewal applications must be filed by March 1, 2019 *** Tax ID No.: For Office Use
More informationANNUITY CLAIMANT STATEMENT
ANNUITY CLAIMANT STATEMENT Group Annuities and Supplemental Contracts Section 1. GENERAL INSTRUCTIONS Please sign and return the completed form along with a copy of the Certified Death Certificate for
More informationCarroll County Department of Community Development
Carroll County Department of Community Development 423 College Street; P.O. Box 338, Carrollton, GA 30117 770.830.5861 APPLICATION FOR A NEW OCCUPATIONAL TAX CERTIFICATE Step 1: Have staff complete the
More informationSMALL BUSINESS APPLICATION AFFIDAVIT & SIGNATURE
SMALL BUSINESS APPLICATION AFFIDAVIT & SIGNATURE Carefully read the attached affidavit in its entirety. Enter the required information for each blank space. Once completed, please sign and date the affidavit
More informationTOWN OF BRASELTON Business/Occupation Tax Renewal Application
TOWN OF BRASELTON Business/Occupation Tax Renewal Application Instructions: Please print or type and return application in person or by mail with your payment. All renewals are due to Town Hall by November
More informationHumana Insurance Company Hospital Indemnity Claim Filing Instructions
Humana Insurance Company Hospital Indemnity Claim Filing Instructions Page 1 Insured s Statement of Claim: Must be completed each time you file a claim. Be sure to answer every question. Page 2 Authorization
More informationBusiness License Application (January 1 December 31)
4035 WALNUT CIRCLE / P.O. BOX 99 OAKWOOD GA 30566 770-534-2365 Business License Application (January 1 December 31) Date: Please check one: [ ] Mail (if mailed, please add and $1.25 for postage) [ ] Pick-up
More informationEnrollment Request Form
Employer name: Coverage effective date: Employer group number (Medical): Important Please print all sections in black ink. For the application to be valid, you must submit all applicable pages. 1. Select
More informationIN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION., ) ) Petitioner, ) ) Civil Action File No. and ) ), ) ) Respondent.
IN THE SUPERIOR COURT OF FULTON COUNTY FAMILY DIVISION, Petitioner, Civil Action File No. and, Respondent. REQUIRED DOCUMENTS TO BE PRODUCED No later than thirty (30 days from the filing of the Complaint,
More informationESCORT INFORMATION SHEET
ESCORT INFORMATION SHEET The materials listed below are needed to file all applications except Alcohol Applications. 1. Duplicate Applications Answer all questions appropriately and in detail, legibly,
More informationInstructions for Completing the ID Theft Affidavit
Instructions for Completing the ID Theft Affidavit To make certain that you do not become responsible for the debts incurred by the identity thief, you must provide proof that you didn t create the debt
More informationGROUP TERM LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PORTABILITY APPLICATION
Continental American Insurance Company (the Company ) 300 Southborough Drive, Suite 200, South Portland, ME 04106 Telephone: 1-888-862-5732; Fax: 1-877-820-5311 GROUP TERM LIFE AND ACCIDENTAL DEATH AND
More informationResidence Homestead Exemption Application
Residence Homestead Exemption Application Appraisal District s Name Phone (area code and number) Appraisal District Address, City, State, ZIP Code Website address (if applicable) GENERAL INSTRUCTIONS This
More informationAccident Medical Claim Form
137 Main Street Dubuque, IA Accident Medical Claim Form Please read and follow these instructions should there be a need to file a claim for a covered accident. Your policy says you must notify us of your
More informationThe party making the request and the assigned mediator will be notified whether the request is granted prior to the mediation session.
CARROLL COUNTY MEDIATION CENTER ALTERNATIVE DISPUTE RESOLUTION PROGRAM CARROLL COUNTY COURTHOUSE 311 NEWNAN STREET (3 RD FLOOR) CARROLLTON, GA 30117 PHONE: 770-830-5993 / FAX: 770-830-0434 The party requesting
More informationINSTRUCTIONS FOR FICTITIOUS BUSINESS NAME (FBN) STATEMENT AND AFFIDAVIT OF IDENTITY
INSTRUCTIONS FOR FICTITIOUS BUSINESS NAME (FBN) STATEMENT AND AFFIDAVIT OF IDENTITY The form must be legible no erasures or whiteouts. Strikeovers acceptable if accompanied with initials. 1. IN PERSON:
More informationFBN Requirements (SB 1467)
FBN Requirements (SB 1467) Effective January 1, 2015, pursuant to Senate Bill 1467, the Los Angeles County Registrar/Recorder County Clerk s Office will require a Notarized Affidavit of Identity form to
More informationMAYOR S OFFICE OF HOUSING CITY AND COUNTY OF SAN FRANCISCO
MAYOR S OFFICE OF HOUSING CITY AND COUNTY OF SAN FRANCISCO GAVIN NEWSOM MAYOR MATTHEW O. FRANKLIN DIRECTOR Dear Renter, DO NOT SUBMIT THIS APPLICATION TO THE MAYOR S OFFICE OF HOUSING. SEE INSTRUCTIONS.
More informationIf you should have any questions about the process for obtaining your 2016 Occupational License please contact the City Hall:
Dear Home Occupation Owner: Attached is the application for a Home Occupation Tax Certificate. All Home Occupation Tax Certificates must be approved by City Council. Please note that the application must
More informationDomestic Partner Forms
Domestic Partner Forms Version: 2.2 Suffolk County Municipal Employee Benefit Fund 30 Orville Dr. Suite D Bohemia, NY 11716-2513 Eligibility Division wendyz@scmebf.org 631-319-4099 ext. 321 631-218-7970
More informationIdentity Theft Victim s Packet
Revised April 2010 Identity Theft Victim s Packet Information and Instructions This packet is to be completed once you have contacted the El Paso County Sheriff s Office and obtained a police report number
More informationBell County Justice of The Peace, Precinct 2 Judge Don Engleking
This section to be filled out by Court Personnel AFFIDAVIT OF INDIGENCE No/s. list cause numbers State of Texas In the Justice Court vs. Precinct 2 DEFENDANTS NAME Bell County Offense/s: offense as listed
More informationRETIREE MEDICAL PLAN ELECTION FORM
RETIREE MEDICAL PLAN ELECTION FORM OBI Retiree Trust Medical plan is underwritten by: Transamerica Premier Life Insurance Company (Employer PDP) You must return your election form to put your coverage
More informationForm 13.2 Affidavit in Forma Pauperis. The Affidavit in Forma Pauperis must be in the following form:
Form 13.2 Affidavit in Forma Pauperis The Affidavit in Forma Pauperis must be in the following form: I,, state that I am a poor person without funds or property or relatives willing to assist me in paying
More informationINSTRUCTIONS FOR FILING A CLAIM LIMITED BENEFIT CANCER EXPENSE POLICY
INSTRUCTIONS FOR FILING A CLAIM LIMITED BENEFIT CANCER EXPENSE POLICY The forms must be completed by the claimant. All questions on the forms must be answered in full. Incomplete or illegible answers may
More informationID Theft Toolkit and Affidavit
ID Theft Toolkit and Affidavit Identification Theft Toolkit Safeguard yourself from ID Theft ID Theft the unauthorized and illegal use of your name, Social Security number or other personal information
More informationFBN Requirements (SB 1467)
FBN Requirements (SB 1467) Effective January 1, 2015, pursuant to Senate Bill 1467, the Los Angeles County Registrar/Recorder County Clerk s Office will require a Notarized Affidavit of Identity form to
More informationMONTANA JUDICIAL DISTRICT COURT COUNTY
Name Address City State Zip Code Phone Number [ ] PETITIONER/[ ] RESPONDENT PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage of:, Petitioner, and, Respondent. Cause No.: [ ] Petitioner
More informationIdentity Theft Victim s Packet
Identity Theft Victim s Packet Information and Instructions This packet is to be completed once you have contacted Reno Police Department, complete a crime report and obtained a police report case number
More informationLife Insurance Claimant s Statement
Life Insurance Claimant s Statement Policy Policy number(s) Information Name of Deceased Other names by which the deceased may have been known 55 No. 300 West, Suite 375 Salt Lake City, Utah 84101 (801)
More informationProgressive Services, Inc. 401(k) Salary Reduction Plan
eneficiary Designation 401(k) Plan Progressive Services, Inc. 401(k) Salary Reduction Plan 503260-01 For My Information For questions regarding this form, visit the website at empowermyretirement.com or
More informationOFFICIAL RULES NO PURCHASE NECESSARY; VOID WHERE PROHIBITED.
OFFICIAL RULES NO PURCHASE NECESSARY; VOID WHERE PROHIBITED. SWEEPSTAKES: The Fiesta Selfie Sweepstakes (the Sweepstakes ) will be conducted beginning at 12:00 a.m. C.T. on April 19, 2018 and ending at
More informationCity of Torrance Defined Contribution Plan - Exec/Management
Beneficiary Designation 401(a) Plan City of Torrance Defined Contribution Plan - Exec/Management 98215-06 For My Information For questions regarding this form, visit the website at www.torrance457.com
More informationNAU Police Department s Identity Theft Victim s Packet
NAU Police Department s Identity Theft Victim s Packet Information and Instructions This packet should be completed once you have contacted the NAU Police Department and obtained a police report number
More informationSMALL ESTATE AFFIDAVIT CHECKLIST
SMALL ESTATE AFFIDAVIT CHECKLIST Texas Estates Code Chapter 205 deals with Small Estate Affidavits (SEA). SEA can only be filed in limited circumstances. Before filing an SEA, carefully review this checklist.
More informationApplication/Change Form For Individual Dental Insurance
U?Te Empl And its Affiliates and Subsidiaries P.O. Box 659020, Sacramento, CA 95865 Application/Change Form For Individual Dental Insurance AGENT/AGENCY INFORMATION Please print clearly and mark carefully.
More informationCovering Calendar Year: Mailing Address: Street or P.O. Box City County State Zip code. ( )
CFC PFD Rev. 1/14 STATE OF GEORGIA PERSONAL FINANCIAL DISCLOSURE STATEMENT 200 Piedmont Avenue S.E. Suite 1402 West Tower Atlanta, GA 30334 404-463-1980 www.ethics.ga.gov Local Location Code: Original
More informationSun Life Assurance Company of Canada
Sun Life Assurance Company of Canada Death Benefits Claim Packet Instructions for the Plan Administrator In the event of the death of an insured employee or dependent, please follow these steps as soon
More informationHADDON TOWNSHIP BOARD OF EDUCATION 500 RHOADS AVENUE WESTMONT, NJ REQUEST FOR PROPOSAL
A. PURPOSE: HADDON TOWNSHIP BOARD OF EDUCATION 500 RHOADS AVENUE WESTMONT, NJ 08108 REQUEST FOR PROPOSAL The Haddon Township Board of Education is seeking proposals from qualified respondents as follows:
More informationPay Card - Recipient Frequently Asked Questions
Q: How soon will my card arrive? A: You should receive your card in 7-10 business days. A complete Pay Card Disclosure and Terms and Conditions will accompany the card. If you do not receive your card,
More informationDeductible Reimbursement Proof of Loss Claim #:
Deductible Reimbursement Proof of Loss Claim #: Please be advised that this is a generic claim form and may refer to several types of coverages. This does not imply or suggest that your policy contains
More informationTOWN OF BRASELTON Business/Occupation Tax Application
TOWN OF BRASELTON Business/Occupation Tax Application Instructions: Please print or type and return application in person or by mail with your payment. All renewals are due to Town Hall by November 15
More informationAugsburg College. Wells Fargo Bank Commercial Card Program. Policy and Procedures Manual
Augsburg College Wells Fargo Bank Commercial Card Program Policy and Procedures Manual 1 Table of Contents Introduction... 3 General Guidelines Card Issuance... 4 Account Maintenance... 4 Card Usage...
More informationLast Name First Name M.I. Social Security Number Number
Beneficiary Designation 401(k) Plan White Earth Tribal Government 401(k) Plan 385542-01 For My Information For questions regarding this form, visit the website at www.empower-retirement.com/participant
More informationTake Charge: Fighting Back Against Identity Theft 37
Instructions for Completing the ID Theft Affidavit To make certain that you do not become responsible for any debts incurred by an identity thief, you must prove to each of the companies where accounts
More informationInstructions for Completing the ID Theft Affidavit
Instructions for Completing the ID Theft Affidavit To make certain that you do not become responsible for any debts incurred by an identity thief, you must prove to each of the companies where accounts
More informationCHECKLIST OF REQUIRED ITEMS FOR LIQUOR LICENSE APPLICATIONS
Matthew Brantner Director of Liquor Control CHECKLIST OF REQUIRED ITEMS FOR LIQUOR LICENSE APPLICATIONS Completed Application Affidavit Completed Personal Information Application Competed Application for
More informationTexas Funeral Service Commission Funeral Establishment Application Guidelines
Texas Funeral Service Commission Funeral Establishment Application Guidelines All applicants when applying for a new establishment license must comply with Texas Occupations Code Section 651.351, Funeral
More informationSTATE OF NORTH CAROLINA DEPARTMENT OF INSURANCE BIOGRAPHICAL AFFIDAVIT FOR ADMINISTRATORS
Full Name of Administrator STATE OF NORTH CAROLINA DEPARTMENT OF INSURANCE BIOGRAPHICAL AFFIDAVIT FOR ADMINISTRATORS In connection with the above-named administrator, I herewith make representations and
More informationLISH Hawaii Limited Benefit Medical Plan Employer Checklist
LISH Hawaii Limited Benefit Medical Plan Employer Checklist Thank you for your interest in the Limited Benefit Medical Plan offered to you by LISH Hawaii. In order to enroll in this plan, you will need
More informationDelaware Division of Corporations 401 Federal Street Suite 4 Dover, DE Phone: Fax:
Delaware Division of Corporations 401 Federal Street Suite 4 Dover, DE 19901 Phone: 302-739-3073 Fax: 302-739-3812 TRADEMARK AND/OR SERVICE MARK RENEWAL FORM Dear Sir or Madam: As requested, enclosed is
More informationNC General Statutes - Chapter 14 Article 19B 1
Article 19B. Financial Transaction Card Crime Act. 14-113.8. Definitions. The following words and phrases as used in this Chapter, unless a different meaning is plainly required by the context, shall have
More informationTown of Braselton Occupational Tax Certificate Application NEW: Return original copy before commencing operations
Town of Braselton Occupational Tax Certificate Application NEW: Return original copy before commencing operations RENEWAL: REMIT TO: Return original copy before November 15 th Town of Braselton 4982 Hwy
More informationWoodmenLife 401(k) Plan
Beneficiary Designation 401(k) Plan WoodmenLife 401(k) Plan 194505-01 For My Information For questions regarding this form, visit the website at www.empower-retirement.com/participant or contact Service
More informationBIDDER S QUALIFICATION AND EXPERIENCE STATEMENT
BIDDER S QUALIFICATION AND EXPERIENCE STATEMENT The OWNER will require supporting evidence regarding Bidder s Qualifications and competency. The Bidder will be required to furnish all of the applicable
More informationApplication begins on page 3
INSTRUCTIONS FOR COMPLETING DBPR ABT 6029 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR EXTENSION OF LICENSED PREMISES OR AMENDED SKETCH OF LICENSED PREMISES Application begins on page 3
More informationAPPLICATION FOR EXEMPTION OF GOODS EXPORTED FROM TEXAS ("FREEPORT EXEMPTION") FOR 2010
Division - Freeport Exemption P.O. Box 560367 * Dallas, Texas 75356-0367 www.dallascad.org APPLICATION FOR EXEMPTION OF GOODS EXPORTED FROM TEXAS ("FREEPORT EXEMPTION") FOR 2010 This application covers
More informationMUST BE SIGNED TO BE VALID
REQUEST FOR PROPOSAL 5874 AMENDMENT 1 TITLE: LIFE, VOLUNTARY LIFE, AD&D, AND LTD INSURANCE DATE: AUGUST 2, 2017 BUYER: EMAIL: LYNDA SEABAUGH ASSISTANT CONTROLLER lseabaugh@semo.edu PHONE: (573) 651-2076
More informationCANYON COUNTY LIQUOR LICENSE APPLICATION NEW TRANSFER ( APPLICANT LOCATION)
CANYON COUNTY LIQUOR LICENSE APPLICATION (PLEASE CHECK ONE) NEW TRANSFER ( APPLICANT LOCATION) 1. APPLICANT NAME: (INDIVIDUAL, CORPORATION, LLC, PARTNERSHIP OR OTHER BUSINESS ENTITY) 2. NAME OF BUSINESS
More informationMinimum Distribution Request
Minimum Distribution Request Section A. Plan Sponsor Information Plan Sponsor Name Contract/Account No. Affiliate No. Section B. Member Information Social Security No. of Birth (mm/dd/yyyy) First Name/Middle
More informationIN THE SUPERIOR COURT OF COUNTY STATE OF GEORGIA., ) ) Petitioner, ) ) Civil Action File No. vs. ) ), ) ) Respondent. ) ) ANSWERS TO INTERROGATORIES
IN THE SUPERIOR COURT OF COUNTY STATE OF GEORGIA, Petitioner, Civil Action File No vs, Respondent ANSWERS TO INTERROGATORIES No later than thirty (30 days from the filing of the Complaint, each party is
More informationVisa Credit Card Policy and Procedures Manual May 1, 2009
1 Visa Credit Card Policy and Procedures Manual May 1, 2009 Table of Contents Introduction... 3 General Guidelines... 4 Card Issuance... 4 Account Maintenance... 4 Card Usage... 4 Limitations and Restrictions...
More informationLOYAL AMERICAN LIFE INSURANCE COMPANY PO BOX 1604, DUNCAN, OKLAHOMA, Phone (800)
INSTRUCTIONS FOR FILING A MEDICAL CLAIM CANCER TREATMENT The forms must be completed by the claimant. All questions on the forms must be answered in full. Incomplete or illegible answers may result in
More informationMONROE COUNTY SHERIFF S OFFICE. General Order
MONROE COUNTY SHERIFF S OFFICE General Order CHAPTER: 34 - D EFFECTIVE DATE: August 19, 2009 REFERENCE: CALEA 42.2.8 NO. PAGES: 8 TITLE: Identification Theft Investigation Procedures AMENDED: RESCINDS:
More informationSupplemental Insurance Claim Form Packet
Supplemental Insurance Claim Form Packet The Chesapeake Life Insurance Company strives to provide easy and accurate claim filing information to our Insured. This packet contains all the required forms
More informationPrimary applicant s last name: First name: MI: Male Female Billing address: City: State: ZIP: County applicant resides in:
Application must be typed or completed in blue or black ink. Effective date of coverage: Coverage is only available for enrollment during the annual open enrollment period, which is November 1, 2015, through
More informationBaggage Delay. Helpful Tips. Call for help: (toll free) or (worldwide) or (collect)
Call for help: 800-461-6920 (toll free) or 317-582-2629 (worldwide) or 317-818-2809 (collect) Baggage Delay Claim Helpful Tips º º Include documentation from your common carrier (airline, cruise line,
More informationIDENTITY THEFT REPORTING
Davis Police Department 2600 Fifth Street - Davis, California 95618-7718 Business: (530) 747-5400 - Fax: (530) 757-7102 - TDD: (530) 757-5666 Administration: (530) 747-5405 - Investigations: (530) 747-5430
More informationAPPLICATION TO TRANSFER CAPITAL CREDIT ACCOUNT OF DECEASED MEMBER
FLORIDA KEYS ELECTRIC COOPERATIVE ASSOCIATION, INC. PO BOX 377 TAVERNIER, FL 33070 (305) 852-2431 (800) 858-8845 APPLICATION TO TRANSFER CAPITAL CREDIT ACCOUNT OF DECEASED MEMBER INSTRUCTIONS: Please complete
More informationCPAOnePro Risk Purchasing Group Application
Underwritten by The Hanover Insurance Company CPAOnePro Risk Purchasing Group Application CLAIMS-MADE WARNING FOR APPLICATION THIS POLICY PROVIDES COVERAGE ON A CLAIMS-MADE BASIS. SUBJECT TO ITS TERMS,
More informationCHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS
CHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS GETTING STARTED Follow the Claimant Instructions below to complete the
More informationSPECIAL EVENT ALCOHOLIC BEVERAGE INSTRUCTION SHEET
SPECIAL EVENT ALCOHOLIC BEVERAGE INSTRUCTION SHEET SATISFACTORY COMPLETION OF THE FOLLOWING REQUIREMENTS ARE NECESSARY TO FILE APPLICATIONS. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. 1. TWO ORIGINAL
More informationAFFIDAVIT REGARDING OTHER INSURANCE. BEFORE ME, on this day personally appeared [claimant], who first being duly
Claimant Claim No. Estate Adjuster STATE OF TEXAS: COUNTY OF AFFIDAVIT REGARDING OTHER INSURANCE BEFORE ME, on this day personally appeared [claimant], who first being duly sworn did upon [his/her] oath
More information