Credit Card Fraud Documentation Report

In-Jurisdiction Use Only - Lakewood, Colorado for amounts not exceeding $1000
The Lakewood Police Department will not investigate - reporting purposes only 

Information submitted using this website is secure.
 

Note: To use this report, the business where the transaction occurred must be located in Lakewood, Colorado. 

For information about all other credit card fraud reports, please contact the Police Department Economic Crimes unit at:
(303) 987-7270 or (303) 987-7275.

This form should ONLY be used if the following criteria are met:

You MUST Select Each Checkbox To Indicate That The Criteria Are Acknowledged:


 

Account Holder First Name: 

Account Holder Last Name:

Account Holder Date of Birth: 

Account Holder Driver's License Number: 

Account Holder Driver's License State:

Address: 

City: 

     

State:

       

Zipcode:

       

Telephone Number: 

Other Phone Number:

E-Mail Address:

 

 

 Name of Business(es)/Institution(s) where card was used:


Business must be located in Lakewood, Colorado to meet jurisdiction requirements, if the card was used at more than 3 locations, please indicate the addional locations and total number of transactions in the narrative section below.

 

First Business Name: 

Business Address: 

Business City:

Business State:

 

Transaction Date: 

 [None] Select a Date Delete the Date

Transaction Amount: $ 

 

Second Business Name: 

Business Address: 

Business City:

Business State:

 

Transaction Date: 

 [None] Select a Date Delete the Date

Transaction Amount: $ 

 

Third Business Name: 

Business Address: 

Business City:

Business State:

 

Transaction Date: 

 [None] Select a Date Delete the Date

Transaction Amount: $ 

 
Total amount of transaction loss:
 
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!
Last 4 numbers of the account Number on the Credit/Debit Card:
 
Last four digits of Social Security Number associated with account: XXX-XX-
 
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.  I am reporting that another person obtained or recorded, by means of fraud, theft or other violation, my personal indentifying information without my authorization, and the person used the information to obtain or attempt to obtain credit, goods, services or funds in my name without my consent.
 
  
To obtain an official copy of this report, fill out the Police Records Request Form and contact:
   Lakewood Police Department Records Section:
   Public Safety Building
   445 South Allison Pkwy
   Lakewood, Colorado 80226
   Telephone 303-987-7336
 
If you have questions concerning this form, please contact the Lakewood Police Department Economic Crime Unit at:
303-987-7270