First, make sure to update the regulatory citation to the CFPB's Reg E 1005.11(b)(2). Second, since the customer is face to face with you, note there is no requirement that you provide the customer with an address on your written form. In this case you'd say, "Here, sign this please." The address in this case happens to be the one they are at. If you accept a claim over the phone and have to mail a form to the customer, then you should be providing an address to which the form should be returned. Note that the explanations about provisional credit on this form do not satisfy the requirement in 1005.11(c)(2)(ii) to notify the customer within 2 business days of providing the provisional credit.
Since you are always permitted to do more for the customer, you can choose to include information about VISA's 5 business day requirement for provisional credit on claims involving fraud. Again, make sure that you notify the customer after you have provided the provisional credit.
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