<p> ®</p><p>CBA Shipment Undeliverable Form Citibank® Government Travel Card Program</p><p>Instructions: Date: Attention: Citi Card Deployment Team CPMs/APCs complete this form to report issues with Centrally Billed Accounts (CBAs). Please Type or Print the information. Note: New applications will be available on Nov. 10 at 757-857-0894 OR 757-857-0895 http://www.citimanager.com/dodhome. Citi will continue receiving periodic updates from your current provider through Nov. 14. New accounts and existing account updates will be Toll Free: 866-951-8005 captured through November 14 and new Citi cards will be mailed if applicable. . *Indicates Fax: required field. Please TYPE or PRINT information. 1. Fax completed form to the Citi Card Deployment team Collect: 757-818-6893 2. Maintain copy for CPM / APC file Section I: Central Account Information White Plastic Transaction Agency*: Account Type*: Army Navy Air Force Marine Corps Independent Unit Card Citi Account Please provide the last 12 digits of the Citi account number using the crosswalk spreadsheet provided to you by your service CPM Number*: x x x x Section II: Card Receipt Information Reason for Reissue* Card Not Received Card Destroyed In Error Card Name Incorrect Card Address Incorrect Only enter information to be changed as it relates to the card. Card name changes can only be made for the white plastics. </p><p>Card Name:</p><p>Attention: Address Line </p><p>Information to 1: be Updated Address Line </p><p>2: Zip/Postal City: State: Code: Country: Commercial Commercial Fax: Phone: If no selection is made from the options below, the card will be mailed standard delivery Delivery Method* Standard Expedited ($20 delivery fee)</p><p>Section III: Account Closure Information Complete this section when closing an account ONLY. Close Account: If closing a Unit Card account, indicate the reason for closure: Yes APC Request Cardholder Deceased Cardholder no longer employed Section IV: Additional Details </p><p>Additional </p><p>Details:</p><p>Section V: Authorization The individual completing this form must be an APC or CPM. APC / CPM Information*: Print or type Name and Title Business Phone (Commercial Access Number Required – Ext.</p><p>Signature Date</p><p>Global Transaction Services © Citibank (South Dakota), N.A. All rights reserved. Citi and Arc Design and Citibank are service marks of Citigroup Inc. or its affiliates, used and registered throughout the world.</p><p>CB087DoD 1 of 2 ®</p><p>CBA Shipment Undeliverable Form Citibank® Government Travel Card Program</p><p>Instructions Sheet Purpose: APCs / CPMs complete this form to report Department of Defense Centrally Billed Travel Cards that were not received, need to be closed, or to report a change. All fields marked with an asterisk (*) are required. Instructions: Who: This form is to be completed by the Agency Program Manager (APC) or the Component Program Manager (CPM). When: Complete this form when there is a need to report a card reissued, closed or to report a change. How: Central Account Information  Transaction Account Type (required): Indicate if the card is a white plastic (previously a Section I: cardless transaction account) or a unit card  Agency (required): Indicate the agency to which the card is assigned</p><p>Card Receipt Information  Reason for Reissue (required): Select the best option  Information to be updated: Provide the information to be changed as it relates to the card. Card name changes can only be made for the white plastics. Section II:  Address (lines 1 & 2), City, State, Zip/Postal Code & Country: Enter the complete address to where the new plastic should be mailed. Use the additional details section to provide any additional information (i.e., if the billing address is different).  Delivery Method (required): select the best option. Account Closure Information Section III:  Close Account: Only complete if you want to close an account. For unit cards please indicate the reason for the closure. Additional Details Section IV:  Additional Details: Please provide any additional information we need to complete your request. Authorization:  Print or Type: Enter name (print or type) and title of APC / CPM completing this form  Business Phone: Enter the APC / CPM commercially accessible business telephone Section V: numbers, including area / country code and extension, if applicable  Signature: APC / CPM signature  Date: Enter the date the form is signed by APC / CPM</p><p>Submit Request form with supporting documentation via fax to: Attention: Citi Card Deployment Team</p><p>Fax Numbers: 757-857-0894 OR 757-857-0895 Toll Free: 866-951-8005 Collect: 757-818-6893</p><p>Global Transaction Services © Citibank (South Dakota), N.A. All rights reserved. Citi and Arc Design and Citibank are service marks of Citigroup Inc. or its affiliates, used and registered throughout the world.</p><p>CB087DoD 2 of 2</p>