Affidavit of Unauthorized Use

INSTRUCTIONS: Complete all applicable fields, including the list of transactions youre disputing. If you need more
space, please use a separate sheet. Be sure to sign and date the bottom of this form or we will need to return the form to
you for signature.
Customer Information

Neloshan Selvakumaran
Full Name: ______________________________________________________
+14169022100
Customer Number: ______________________________________________________
300 N State St, apt. 3903, Chicago, Illinois
Address: ______________________________________________________
+14169022100
Primary Phone Number: _____________________________________________________
4900770003248490
Card Number.:_______________________________________________________
Transaction Information
By completing this form, I certify that I didnt use or authorize the use of my card to make the transactions listed below
and:
1. At the time the purchases were made, the card (check one)
2. If not in your possession, the card was (check one)
3. Because of unauthorized use on my card, I (check one)

was

lost
have

wasnt in my possession.

stolen at the time of the transactions.

have not requested a new card.

Transaction Date
Merchant Name
Transaction Amount
_________________________________________________________________________________________________

February 2, 2014 - Starbucks: $1.93

_________________________________________________________________________________________________
February 3, 2014 - Deuces & The Diamond Club : $50.00, $8.80, $15.40, $50.00, $87.00, $70.00, $100.10
_________________________________________________________________________________________________
February 3, 2014 - Dimos Pizza: $11.25
February 3, 2014: Zakaria Ghofal Tadla: $14.25
_________________________________________________________________________________________________
February 3, 2014 - Chi Taxi: $20.00
_______________________________________________
I, nor any person authorized by me, received any cash or service from theses transactions or benefited directly or
indirectly. I realize the information provided here must be the truth to the best of my knowledge or I may be subject to civil
liability and criminal penalties. Im willing to testify in court to the facts sworn in this statement.

2/4/2014
Neloshan Selvakumaran
Cardholder Signature:_______________________________________________
Date:___________
Guardian Signature (When Applicable):_________________________________Date:____________
Return the form and any supporting documentation as soon as possible by fax to 724-779-2479.
Please note that this form and any supporting documentation must be returned in a timely manner to avoid
having any provisional credit that may have been applied to your account revoked.
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RBC Bank (Georgia), N.A. 2012