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					 requeSt replacement of a                                                                                                      for office uSe only
 loSt, Stolen or damaged
                                                                                                               CSN ___________________________ Auth. ___________________________
 tranSlink® card
                                                                                             ®
 For	registered	TransLink	cardholders	only                                                                     CSR ___________________________ Ref.# ___________________________



 Please use this form to request replacement of a registered lost, stolen or damaged TransLink card. A damaged card means it has a part broken off, a hole has been
 punched through it, or it has been cracked, bent, punctured or otherwise altered. If your unregistered card is lost, stolen or damaged, use the “TransLink ® Card
 Order and Registration” form to request a new card.

 Step 1: card Serial number and StatuS
 If you have your TransLink card, enter your card serial number, which is printed on the back of your card.         please indicate the status of your card:
 Enter all the digits before the dash, including zeroes. If you do not have your TransLink card, we can only
 process your request if the information on this form matches the information you previously provided.
                                                                                                                     Lost
                                                                                                                     Stolen
 Card Serial Number: ____________________________________________________________________                            Damaged
 Step 2: cardholder contact information
	 *REQUIRED
	 *First Name ______________________________ Middle Initial ________ *Last Name _____________________________________________________________

 *Billing Address ___________________________________________ Apt. # ______ *City __________________________ *State ______ *Zip ______________

 Shipping Address (if	different) ___________________________________ Apt. # ______ City ___________________________ State ______ Zip ______________

 *Day Phone ( _____ ) _____________________ *Evening Phone ( _____ ) ______________________ *Email ___________________________________________

 Step 3: replacement and balance reStoration requeSt (required)
  Replace card. ($5 card replacement fee*)							 Replace card and restore balance. ($5 card replacement fee* and $5 balance restoration fee)
 *The	$5	card	replacement	fee	will	be	waived	if	you	have	set	up	Autoload.		

 Step 4: amount due (required)
 You will be charged a $5 card replacement fee. The $5 replacement fee will be
 waived if you have set up Autoload. If you also have requested that your balance                 Card Replacement Fee ($5):              $ _________________________
 be restored, you will be charged an additional $5 balance restoration fee (but if
 you have less than $5 in value on your card, your request will not be processed).                 I have Autoload.                           No Fee
 These fees will be charged to your credit card.
                                                                                                  Balance Restoration Fee ($5):           $ _________________________

                                                                                                  total:                                  $ _________________________

 Step 5: credit card payment detailS and authorization (required)
 Credit Card Account* (check one):          MasterCard         Visa            Discover

 Credit Card Number _____________________________________________________ Expiration Date (mo/yr) _________________________________________
 *Please	make	sure	that	the	billing	address	you	provided	above	matches	the	billing	address	for	this	account.

 By signing, I authorize the Metropolitan Transportation Commission or its agent, Motorola, Inc., acting through its subcontractor, ERG Transit Systems (USA), Inc.,
 to transfer funds from the credit card account to pay for the fee(s) designated in Step 4.


 Signature ________________________________________________________________________________________                    Date ______________________________________

 Step 6: Submit form
 please mail your completed form to:             translink customer Service center
                                                 p.o. box 318
                                                 concord, ca 94522-0318
 or fax it to:                                   1-925-686-8221

 You will receive a replacement card with your balance restored within five (5) business days of the time the TransLink Customer Service Center receives your request.
 For faster service, you can request a replacement card online by visiting www.translink.org and logging into your My TransLink account. If you have questions about your
 request, please call 1-877-878-8883 (TTY/TDD 711 or 1-800-735-2929).
 The amount restored to your card will match the value on your TransLink card at the end of the business day that the TransLink Customer Service Center receives
 your request.
 If you would like to request a refund for a registered lost or stolen card, please use the “Request a TransLink® Card Refund” form.

				
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