AMERICAN EXPRESS GLOBAL PREPAID

Instructions:

1. Please launch and print the document.

Note: To download this document, you must have Adobe^® Acrobat^® Reader^® 4.0 or higher (excluding 6.0) installed on your computer.

2. Complete the form with the details requested.

3. Fax or mail the completed form along with copies of any other supporting documentation related to your request, such as receipts or monthly statements, to:

• Customer Relations Team Fax number:
  • (801) 945-2711 (U.S. only)
  • +1 801 945-2711 (outside U.S.)

• Customer Relations Team Mailing address:

American Express Customer Relations

4315 South 2700 West

Salt Lake City, UT 84184-0440

USA

Note: Keep your original submission for your personal records.