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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 for residents of the Town of Greenwich, who was the victim of Identity Theft, not a resident but employed in the Town of Greenwich, or the actual 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 Theftoccurred, name and address of where ID Theft related items were mailed.

  4. If you want to be entered as a File 10 in the COLLECT system, you will need to respond to the Public Saftey Complex with a completed COLLECT File 10. This form can be printed and filled out from the GPD website.

  5. You may be advised of the need to complete a written sworn statement. You can print out the statement paperwork and complete it prior to coming to the Police Department. However, it must be signed in the presence of a Police Officer.

  6. Are you willing to assist in the prosecution of the persons responsible*

  7. Has the Financial Institution/Creditor/Bus. assumed the loss and are holding 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 with 72 hours, contact the Greenwich Police Department immediately at 203-622-8004 to report this incident to the 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.

  32. Leave This Blank:

  33. This field is not part of the form submission.