Fraudulent Use of Credit or Debit card

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Unauthorized use of your credit or debit card by an unknown person.

Someone unknown to you has stolen your credit or debit card number only and used it to make purchases or charges without your permission. Please provide the 16-digit card number with the specific date, time and locations of the fraudulent charges. You will be asked to provide a copy of your bank statement or the Dispute Form you file with your financial institution.

*Report Type

If this is a Supplemental report please provide the Original Report Number

Original Report Number

*Person Type

*First Name

*Last Name

Home Address

*Address

*City

*State/Province

*Postal Code

*Home or Cell Phone

*Email Address

Work Address

If you are filing on behalf of a business.

Business Name

Your Position/ Title

Work Address

Work City

Work State

Zip Code

Work Phone Number

*Race

*Sex

Date of Birth

MM/DD/YYYY

Social Security Number

Drivers License Number

Licensing State

Enter Incident Information

Please enter all the information that applies. If you do not know the address of the incident, use the nearest intersection such as Market St./ 10th St.

*Street Address

*City

*State

*Zip Code

Incident Time

*Date

MM\DD\YYYY

*Time

HH:MM AM or PM

Location Type

Enter Narrative

Please provide the following information for each fraudulent charge: The date, time, location/address, and dollar amount. Please provide the 16-digit card number, type of card, and name of the issuing bank. Please have a copy of your bank statement or the Dispute Form from your financial institution available to forward to Sheriff's Office by email or fax. You can also attach the documents to this form.

file