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2. 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

3. 

5. 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.

7. 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.

9. 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.

13. Victim Type*
    -- Select One --Resident of the Town of GreenwichNot a resident, Employed in the Town of GreenwichActual Theft/Fraud occurred in the Town of Greenwich

    Select one that is most relevant
14. Are you willing to assist in the prosecution of the person(s) responsible?*

    1. Yes
    2. No
15. Has the financial institution/creditor/business assumed the loss and held you harmless?*

    1. Yes
    2. No

    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.

19. Reporting Party/Victim Information
21. Last Name*
22. First Name, Middle *
24. Date of Birth*
25. Address*
27. City*
28. State*
29. Zip Code*
31. Home Telephone*
32. Cell Telephone*
34. Email address*
35. Driver's License Number*
    State-Number
39. 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.

41. 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.
43. Type of Identity Theft-Fraud*

    1. Unauthorized Use of Personal Information
    2. Unauthorized Use of Credit Card/Debit Card
    3. Unauthorized access to Bank/Securities Account
    4. Internet Fraud- Information Stolen when opening or replying to a bogus email/website
    5. Forgery-Someone represented themselves as you and acquired gods or services
    6. Bogus Account in your name- Someone opened a service in your name- cellphones, insurance, cable, etc
    7. Wire Fraud/Business Email Compromise
    8. Scam via email/telephone- IRS Scam, Grandparent Scam, Apple Gift Card Scam, etc
    9. Other- Explain Details in Narrative Section
45. What is the Total Financial Loss*
46. Did you report the loss to your bank or financial institution*

    1. Yes
    2. No
48. Bank Contact Name*
    Type N/A if the answer to the previous question was No
49. Contact Telephone Number*
    Type N/A if the answer to the previous question was No
53. Credit Card/Banking Account Information
    If more than three accounts were compromised, add the subsequent account information in the Narrative Section
55. Type of Account*
    -- Select One --Credit CardDebit CardBank/Securities AccountNot Applicable for my Complaint
57. Account Number*
    Type N/A if not needed
58. Expiration Date*
    Type N/A if not needed
60. Bank*
    Type N/A if not needed
61. Branch Location*
    Type N/A if not needed
63. Name as it Appears on Account*
65. Credit Card Company*

    1. American Express
    2. Discover
    3. Master Card
    4. Visa
    5. Not Applicable for my complaint
67. Type of Account
    -- Select One --Credit CardDebit CardBank/Securities AccountNot Applicable for my Complaint
69. Account Number
70. Expiration Date
72. Bank
73. Branch Location
75. Name as it Appears on Account
77. Credit Card Company

    1. American Express
    2. Discover
    3. Master Card
    4. Visa
    5. Not Applicable for my Complaint
79. Type of Account
    -- Select One --Credit CardDebit CardBank/Securities AccountNot Applicable for my Complaint
81. Account Number
82. Expiration Date
84. Bank
85. Branch Location
87. Name as it Appears on Account
89. Credit Card Copmpany

    1. American Express
    2. Discover
    3. Master Card
    4. Visa
    5. Not Applicable for my Account
93. Suspect Information
95. Do you have the name or any information that can lead to a suspect*

    1. Yes
    2. No

    If yes, list the information in the provided area
97. Name
98. Email Address
100. Address
102. City
103. State
104. Zip Code
106. Phone Number
107. Relationship to you, if there is one
111. Description of Transactions and Fraudulent Activity
113. Fraudulent Transactions*
     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.
115. Do you have any supporting documents (bank statements, credit card bills, loans, etc) to show fraudulent activity*

     1. Yes
     2. No

     If yes, please list them in the narrative field below.
117. Supporting Document Field- if applicable
121. Additional Comments
     Please use this area to add any other information you feel is pertinent to your complaint.
125. 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.
127. 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.

     1. I agree.
129. Electronic Signature
Leave This Blank:


131. 1. Receive an email copy of this form.
132. Email address

     This field is not part of the form submission.

133. Submit

* indicates a required field