• Government Benefits Card Fraud Reimbursement Claim Form

    Use this form to report unauthorized activity on a government benefits card and request reimbursement for the affected amount.

  • Claimant Information

  • Preferred Contact Method*
  • Format: (000) 000-0000.

  • Benefits Card and Incident Details

  • Date Fraud Was Discovered*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date and Time Unauthorized Activity Occurred or Was Noticed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is the Card Currently in Your Possession?*

  • Fraudulent Transaction Information

  • Unauthorized Transaction(s)*
  • Was the card physically stolen?*
  • Was the card lost?*
  • Was the card skimmed or copied?*
  • Were the transactions made without your permission?*

  • Claim Amount and Recovery Status

  • Were any funds recovered or returned?*
  • Have you contacted the merchant or card support team?*

  • Supporting Evidence and Submission Details

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