Please note that there is a $5.00 Replacement Card fee.

Today's Date
		Lost Stolen		When

Member Information Account Number SSN Name (Primary) Name (Joint) Address City St Zip E-mail Address Hm Phone Wk Phone

Card Information VISA# ATM# Signature on Card? Pin Number Stolen? YES NO YES NO Date Last Used Where Last Used Reported to Police? Where YES NO How and Where Lost/Stolen

Other Missing Credit Cards or ID

You may also print this form and fax to (402) 399-0129, mail to Omaha Federal Credit Union, 3001 So. 82nd Ave., Omaha, Nebraska 68124 or stop by one of our four office locations.