Type of Incident (check all that apply)

Incident of unauthorized Credit Card use
Incident of unauthorized Debit Card use

Name of Business(es)/Institution(s) where card was used:
(Business must be located in Lakewood, Colorado to meet jurisdiction requirements)

Total number of unauthorized transactions made:

Use the Narrative of Events section below to write about additional transactions not listed above.

Please provide the following information if applicable:

Type of Card: (i.e. Visa, Sears, Discover)

Name of issuing Financial Institution for Credit/Debit Card: (i.e. Providian Bank)

Be sure you have cancelled the card!

Account Number on the Credit/Debit Card:

Last four digits of Social Security Number associated with account: XXX-XX-

Account Holder Name:
(Exactly as it appears on the card)

Account Holder Date of Birth:    

Account Holder Drivers License Number:

Account Holder Address:
                                              (Street)                          (City)                        (State)        (Zip Code)

Telephone Number:
 (Be sure to include the prefix)     (Home)                             (Cell)                         (Work)

Narrative of Events: Please briefly describe how the credit/debit card was used without your authorization.

Affidavit

I affirm that this information is true and correct: That another person obtained or recorded, by means of fraud, theft or other violation, my personal identifying information without my authorization, and the person used the information to obtain or attempt to obtain credit, goods, services or monies in my name without my consent.

Date of Report:   

Name of Person/AccountHolder Completing Report:

Email Address where you can be contacted:

Your email address is used for contact purposes only. Please review the City's Privacy Policy for more information.

To obtain an official copy of this report, contact:

     Lakewood Police Department Records Section
     Public Safety Building
     445 South Allison Parkway
     Lakewood Colorado 80226
     Telephone (303) 987-7331

If you have questions concerning this form, please contact the Lakewood Police Department Economic Crime Unit at 303-987-7270.

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