CLIENT NAME: JACQUELINE BURGY FUTRELL CARD NUMBER: xxxxxxxxxx 8899

Thank you for notifying our office of the suspected fraudulent activity that has occurred on your H&R Block Emerald Prepaid
Mastercard®.

We recommend written confirmation within (10) business days of a verbal notice. You may use this form for that purpose, or
you may write to us separately. Please review the following transactions you confirmed as fraudulent in your initial report; if
everything is accurate, no need to send anything back (transactions are listed in Central Standard processing time on
subsequent pages of the email). Include a brief statement regarding the fraud; include your signature; and return this form to
one of the following via fax at (816) 817-1823, mail to Error Resolution PO BOX 10150, Kansas City, MO 64171 or by email to
Documents.EC@hrblock.com.

I declare; the below identified transactions were not made by me or by anyone acting upon my authority. If there are
additional fraudulent transactions not identified below, please list them on a separate sheet of paper. If any transactions
listed are valid transactions that you made or authorized, please mark a line through them. Please explain fully the nature of
the card loss/theft. If necessary use an additional sheet of paper.

I did Not Authorize theseTransaction!

I Did Not Use My Card at KROGER!
Fix my account so Nobody CAN Get into
my Account!

Before You Make This Fraud Claim

Fraudulent use means that you have no idea what the transaction is for and never gave anyone your card or PIN number
to use in any manner. Providing the merchant your card for payment and revoking authorization at a later point in time is
not fraudulent use.

I confirm that I did not receive any benefit or value from the fraudulent transactions nor were any of the
fraudulent transactions applied to any use or purpose on my behalf. I also confirm that I am an authorized signer,
or otherwise have authority to act on the account identified in this statement.

01/01/2023 /614
CUSTOMER SIGNATURE: DATE/CONTACT NUMBER: 349-1299

H&R Block Emerald Prepaid Mastercard® is issued by Pathward, N.A., Member FDIC, pursuant to license by Mastercard.
Mastercard and the circles design are registered trademarks of Mastercard International Incorporated.

Rev 9/2022
 Date Time Description Amount

KROGER #9 2161 EAKIN R

12/30/2022 8:43:50 AM COLUMBUS OH $50.75
PURCHASE