Request for Individualized Pcard Security Access Codes

REQUEST FOR INDIVIDUALIZED PCARD SECURITY ACCESS CODES

IF YOU HAVE EXPERIENCED DIFFICULTY COMMUNICATING WITH JPMORGAN CHASE BY TELEPHONE, CONSIDER REQUESTING NEW SECURITY ACCESS CODES. USE THIS FORM

LAST 4 DIGITS OF CARD NUMBER: ______

CARDHOLDER LAST NAME: ______

SPECIFY YOUR PREFERENCE FOR EACH FIELD:

Mother's Maiden

Social Security Number*

Birth Date (mm/yyyy) /

IT IS RECOMMENDED THAT YOU DO NOT PROVIDE REAL PERSONAL DATA FOR THESE SECURITY CODES.

FOR EXAMPLE:

Mother's Maiden MOM

Social Security Number* 99164

Birth Date (mm/yyyy) 08 1988 / YOU MUST BE AT LEAST 18, SO THE YEAR OF BIRTH CANNOT BE LESS THAN 18 YEARS + TODAY’S DATE.

CARDHOLDER SIGNATURE ______DATE ______

BEFORE SUBMITTING THIS REQUEST MAKE A COPY FOR YOUR RECORDS

SUBMIT THIS REQUEST IN A SEALED ENVELOPE MARKED “CONFIDENTIAL” TO THE PCARD PROGRAM ADMINISTARTOR AT MAILCODE 1020.

DO NOT EMAIL THIS REQUEST