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On-Line Identity Theft and Fraud Related Reporting Form

  1. Identity Theft & Related Fraud Initial Reporting Form

    This form is to be used only by residents of the Town of Greenwich who are the victims of identity theft, nonresidents who are employed in the Town of Greenwich, or individuals whose identity theft occurred in the Town of Greenwich

  2. Black badge
  3. Complete the form with as much detail as you can.   Provide all information relating to the theft, including but not limited to the bank account, name and address where money was wired/transferred to, location and store name where ID theft occurred, name and address of where ID theft-related items were mailed.

  4. If you want to enter your ID theft incident into the National Crime Information Center ID Theft file, you must come into the Greenwich Public Safety Complex with a completed COLLECT File 10 form.   This form can be printed from the Town of Greenwich’s Police Department webpage.

  5. You may be advised of the need to complete a written sworn statement.  You can print out and complete the statement paperwork prior to coming into the Police Department; however, you must sign the statement in the presence of a police officer.

  6. Are you willing to assist in the prosecution of the person(s) responsible?*
  7. Has the financial institution/creditor/business assumed the loss and held you harmless?*

    Select yes if you were told they will after you obtain a police report. If you don't know the answer, call your bank or the creditor and inquire about what they will do once you get the police report.

  8. Reporting Party/Victim Information
  9. State-Number
  10. Type of Identity Theft-Fraud Being Reported

    Personal information is information such as date of birth, name, social security number, bank account, and credit card information, or any other information that is personal to only you.

  11. Note: If you are reporting a wire fraud that occurred within the last 72 hours, please contact the Greenwich Police Department immediately at (203) 622-8004 to report the incident to a police dispatcher.
  12. Type of Identity Theft-Fraud*
  13. Did you report the loss to your bank or financial institution*
  14. Type N/A if the answer to the previous question was No
  15. Type N/A if the answer to the previous question was No
  16. Credit Card/Banking Account Information
    If more than three accounts were compromised, add the subsequent account information in the Narrative Section
  17. Type N/A if not needed
  18. Type N/A if not needed
  19. Type N/A if not needed
  20. Type N/A if not needed
  21. Credit Card Company*
  22. Credit Card Company
  23. Credit Card Copmpany
  24. Suspect Information
  25. Do you have the name or any information that can lead to a suspect*
    If yes, list the information in the provided area
  26. Description of Transactions and Fraudulent Activity
  27. Use this narrative field to list the unauthorized transactions. Please explain in detail how you were made aware of the transactions and any information relevant to the complaint. Please list the Date of Transaction, Account# if any, Type of transaction (on-line, wire, etc), Amount, and location.
  28. Do you have any supporting documents (bank statements, credit card bills, loans, etc) to show fraudulent activity*
    If yes, please list them in the narrative field below.
  29. Please use this area to add any other information you feel is pertinent to your complaint.
  30. Signature
    By signing, you declare under penalty of perjury, that the information you provided in this report is true to the best of your knowledge and belief.
  31. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  33. This field is not part of the form submission.