Online Crime Reporting Form

The following information is necessary and also vital if we are to assist you with your problem. Review each item to make sure it is correct before you submit your information. Send a copy of the check(s) (front & back) involved in this case. Do so by either scanned image attached to email, fax, or by US Mail.

Victim's Full Name:
Your Physical Address:
Your Mailing Address:
Your City:
Your County:
Your State:
Your Zip Code:
Your Home Phone Number:
Your Business Phone Number:
Your Fax Number:
Best Time to Call:
Your Driver License or State ID Nbr (State & Nbr): (NECESSARY)
Your Social Security Nbr: (NECESSARY)
Your Date of Birth: (NECESSARY)
Your Age:

CHECK INFORMATION:

THE INFORMATION YOU PROVIDE WILL ENABLE US TO VERIFY ANY CRIMINAL ACTIVITY IN RESPECT TO THE ACCOUNT NUMBER AND ROUTE NUMBER. SHOULD YOU HAVE ANY QUESTION REGARDING THESE TWO ITEMS, CALL OUR OFFICE. DO NOT PROVIDE ANY INFORMATION ON ANY OPEN ACCOUNTS.

IF YOU ARE REPORTING SEVERAL CHECKS, IT IS BEST THAT YOU INDICATE ONE USING THE FORM OUTLINE AND LIST THE OTHERS IN THE NARRATIVE SECTION. THE FOLLOWING INFORMATION WILL BE VERIFIED.

TYPE OF CHECK YOU RECEIVED- PRESS - SELECT CHECK TYPE PERSONAL CHECK JOINT CHECK BUSINESS CHECK COUNTER CHECK DRAFT CASHIER CHECK MONEY ORDER OTHER

TYPE OF CHECK INVOLVED IN THIS CASE- PRESS - SELECT CHECK TYPE PERSONAL CHECK JOINT CHECK BUSINESS CHECK COUNTER CHECK DRAFT CASHIER / OFFICAL CHECK MONEY ORDER OTHER

Did you file an affidavit of forgery with your bank?	Yes	No
Date Filed:
Bank Name:
Bank Address:
Bank Official:
Bank Phone Number:
Bank Fax Number:
Business Name On Check:
Account Name On Check:
Account Number:
Route Number:
Check Number:
Check Number Series (Stolen):
Check Date:
Check Amount:
Payable to Whom:
Signed By Whom:

REASON CHECK RETURNED - PRESS - SELECT REASON FOR RETURN NSF ACCOUNT CLOSED SUBMITTED TWICE STOPPED PAYMENT LOST OR STOLEN CHECK FORGERY COUNTERFEIT REFER TO MAKER INVALID SIGNATURE DO NOT REDEPOSIT UNCOLLECTED FUNDS OTHER

CREDIT CARD INFORMATION

If your personal credit card or debit card in involved in this case, make sure you have canceled all of your credit and debit cards. You can obtain the credit card company phone number on your last billing statement. If a debit card was stolen, contact your bank "NOW." Your liability is different with a debit card than that of a credit card. If you have questions, call our office.

TYPE OF CREDIT CARD STOLEN- PRESS - SELECT CREDIT CARD TYPE VISA MASTERCARD AMERICAN EXPRESS DISCOVER DEBIT CARD GAS CARD CHECK CASHING CARD OTHER

Did you contact your credit card company?	Yes	No
Credit Card Company Name:
Credit Card Company Address:
Company Phone Number:
Company Fax Number:
Name On Credit Card:
Card Number:
Expiration Date:

SUSPECT INFORMATION

To obtain information regarding your check writer, look at the address in the upper left hand corner of the check. Record any information that was written on the check at the time of acceptance. This information is also vital to your recovery process. Should you have a finger print or a picture of the check writer, let us know at once.

If your checks were stolen, and your bank has provided you with a copy of the check, look for any information hand written on check. SEND US COPIES OF ALL CHECKS INVOLVED IN THIS CASE TO OUR OFFICE AT ONCE. Also provide this information below.

Suspect Name:
Suspect Aliases:
Suspect E-Mail Address:
Suspect Full Address:
Suspect Phone:
Suspect Relationship to You:
Suspect DL / ID (State & Nbr):
Suspect SSN:
Suspect DOB:
Suspect Age:
Suspect Height:
Suspect Weight:
Suspect Race:
Suspect Sex:
Suspect Hair:
Suspect Eyes:
Other Features (scars/marks/tattoos):

PROPERTY INFORMATION

Complete this section if you sold your property to someone and a check was used as payment in exchange. If property was shipped by a common carrier such as FEDERAL EXPRESS or UPS, you need to complete this section.

Property Description & Serial Nbr:
Property Value:

DELIVERY PERSON INFORMATION

You will have to contact the shipper for the following information. You will have to be PERSISTENT in obtaining this information. Make sure you explain that you need the information for a criminal report being filed, and further advise them that the driver will have to provide a written and possible a oral statement concerning the delivery of your goods. He will have to provide a description of the person passing the check and accepting the goods.

FIND OUT IF THE DRIVER OBTAINED A DRIVER LICENSE OR SOME OTHER FORM OF IDENTIFICATION FROM THE PERSON PASSING THE CHECK.

If you are not able to obtain the information you are requesting, tell them that you will make sure that all responsible or involved parties (driver, log person, warehouse manager, and terminal manager) will be given subpoenas to appear in court. Usually this will make them change their mind since no one wants to sit all day in court waiting to testify. Plus they do not get paid for being there.

Common Carrier Name:
Carrier Full Address:
Carrier Phone Nbr:
Date Shipped:
Tracking Number:
Name of Delivery Person:
Driver DOB:
Driver Address:
Driver Home Phone:
Driver Work Phone:

COMMUNICATIONS WITH CHECK WRITER

We will require that you forward copies of any and written correspondence or e-mail you received from or mailed to suspect. If you have communicated with the suspect and mailed a letter to him demanding payment, this section is required.

Certified Letter Date:
Who Signed Green Card:
Date Check Deposited:
Date Check Returned:
Date Signed Green Card:

POLICE AGENCY INVOLVED IN CASE

Police Agency Name:
Police Agency Full Address:
Detective Name :
PD Phone Number:
PD Fax Number:
Case Number:

FOR OUR RECORDS

ASSISTANCE

Do you want assistance in the recovery of your stolen property or bad check

Yes

No

THEFT OF YOUR PROPERTY

If you have had your pocket book, check book, Driver License, State ID, social security card, or other personal property stolen from you, please tell us about the theft. Make sure you indicate if you reported the THEFT to your local police department. Provide the name of the police agency and their phone number with the case number assigned to you. If your Driver License and checks were stolen, they may be used at a later date. We will record the information in our data base as long as you provide us with as official Police Crime Report. Should you have questions about this section, call us.

NARRATIVE

Submit a brief narrative of your problem. Make sure you list all the information you have regarding the incident or crime. Tell us the details starting when you became aware of the problem up to current date. If you sold someone an item, tell us how you were contacted. If you received E-Mail from the suspect, be prepared to forward all correspondence between both parties by E-Mail to the CENTER. If you have contacted a police agency, list their name along with their address, phone number, officer contacted, and the complaint number your were assigned. If an arrest warrant has been issued, if available, please indicate the warrant number, date it was issued, and the name of the Police Department involved.