To report a lost or stolen bank card, please complete the form below. Note that fields marked in bold are required. A $5.00 fee may be assessed to your account for a new card.

Card Type	VISA Check Card VISA Credit Card MAC Card - Needs new application
What happened to your card?	Lost Stolen
Card Number:
DEXSTA Account Number:
Cardholder's Name:
Address:
City:
State:	-------- Delaware Maryland New Jersey Pennsylvania -------- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Member's Phone Number:
Date of loss or theft:
City and state where loss or theft occurred:
Date card was last used:
Name of merchant where card was last used:
Amount of last transaction:	$
Describe in detail how the loss or theft occurred: