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.